Policymakers debate whether to use federal health care funding to cover nutrition programs.
More policymakers are supporting programs that use nutrition to address rising levels of diet-related health issues. Should the federal government allocate funding to connect patients with services that tailor food consumption to meet their specific health needs?
At the end of September 2024, U.S. Representative Barbara Lee (D-Calif.) introduced the National Food as Medicine Program Act of 2024, a bill that would mark the first comprehensive step at the federal level to integrate “Food as Medicine” programs into the delivery of health care.
Food as Medicine has been defined as “medically supportive food and nutrition interventions”—services, for example, that health care providers could prescribe as medically necessary for preventing or treating “certain health conditions.” More than a type of clinical intervention, Food as Medicine represents a movement with a policy objective “to expand coverage” of food and nutrition programs using health care delivery systems.
Access to food with adequate nutrition can drive health outcomes, and food insecurity, even at low levels, is linked to premature death and other chronic illnesses. At various points throughout 2023, however, 18 million American households could not access enough food.
Some studies have found that individuals with low incomes are more likely to experience food insecurity and, in turn, may have worse health outcomes and spend more on health care. A growing body of research demonstrates that expanding access to services like Food as Medicine programs could improve health outcomes and reduce health care costs.
Despite mounting support for Food as Medicine programs, insurance coverage remains a challenge. Unlike medications commonly used to prevent or treat chronic disease, public health insurance does not traditionally cover Food as Medicine services.
State legislatures have started to recognize the connection between nutrition and health. In 2016, for example, the Centers for Medicare and Medicaid Services (CMS) first considered a state’s application to use federal funding—through what is known as a Section 1115 Medicaid demonstration waiver—to cover “direct food-based treatments” for Medicaid populations. As of November 2024, CMS has approved 10 state waivers that expand access to Food as Medicine programs for eligible groups.
Once approved by CMS, Section 1115 waivers allow states “to test new approaches in Medicaid that differ from federal program rules.” States authorized to use Medicaid waivers receive federal funds to address “health-related social needs,” such as access to nutritious foods. These funds help cover certain “evidence-based services” that promote Medicaid program goals such as improving health equity and increasing access to affordable health insurance.
Still, Section 1115 waivers are not permanent solutions to gaps in access to health care and social services. Waiver-sponsored nutrition programs may be limited in duration and accessible only to certain Medicaid beneficiaries. Furthermore, the organizations that partner with Medicaid providers to deliver medically tailored food may also face challenges in funding, staffing, and collecting the data needed to demonstrate the efficacy of Food as Medicine programs.
Aside from Medicaid waivers, policymakers have yet to pass legislation requiring expanded Medicaid coverage for Food as Medicine programs.
There is some promise at the state level, however. A bill introduced by California State Assemblymember Mia Bonta (D-Oakland) in January of 2024 would have required California’s Medicaid program to cover “medically supportive food and nutrition” services “determined to be medically necessary by a health care provider or health care plan.”
In September 2024, however, California Governor Gavin Newsom vetoed the bill. Newsom encouraged the legislature to “explore the policy next year,” explaining that the bill would have created “significant and ongoing” costs that were not included in the current budget.
Some health care advocates, on the other hand, oppose using public funds to cover social services such as Food as Medicine programs. Even when efforts to expand the reach of social welfare programs are well reasoned, these advocates contend, that does not mean they should be funded as health care services. Using federal dollars to support these efforts may also raise concerns about fraud and abuse. According to these health care advocates, when program funding is channeled through nonprofit partners, the objectives are difficult to measure.
Other advocates have observed limitations in the research used to promote services such as Food as Medicine programs. When designing studies, for example, researchers may struggle to identify the causal factors driving health outcomes making it difficult to prove that access to food and income level is directly tied to poor health outcomes.
In addition, scholars offer competing evidence in studies suggesting that even when Food as Medicine programs were linked to decreased use of health care services, they did not significantly reduce overall health care spending.
As this debate unfolds, no legislative or regulatory body has identified a long-term funding source for Food as Medicine programs or guaranteed that public health care programs will cover nutrition support services for eligible groups.
Importantly, though, the conversation surrounding Food as Medicine signals a changing tide in how policymakers think about health care, raising questions about what flexibilities exist within the U.S. health care system to redefine what care is and transform how it is delivered.
