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Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
Hello, and welcome to a health podocy. I'm your host, Rob Lott. The food is medicine movement uses food based interventions to address diet related health conditions. Think prescription from your doctor for fresh produce to be redeemed at your local farmers market or think about medically tailored meals for patients with conditions like diabetes or heart disease. These models are among the concepts covered in the April 2025 issue of Health Affairs, a new theme issue dedicated entirely to the intersection of food, health, and nutrition.
Rob Lott:Now although food is medicine typically operates through or partners with clinicians in the healthcare system, not all healthcare payers cover these interventions. Medicaid, for example, typically does not, unless you're in a state that has a waiver to test it, to explore how it might actually work and to study if food is medicine can make a difference in people's health and well-being. Well, one of those states that does have a waiver is Massachusetts and one of those people studying its impact is Doctor. Kurt Hager, an associate professor at the UMass Chan Medical School. We're delighted to have Doctor.
Rob Lott:Hager here with us on today's episode of A Health Odyssey. He has a paper in the April 2025 issue whose title is also its main general finding, quote, Medicaid nutrition supports associated with reductions in hospitalizations and ED visits in Massachusetts from 2020 to 2023. We're so lucky to have doctor Hager here with us. Welcome to this episode of Health Odyssey.
Kurt Hager:Thank you so much. It's wonderful to be here today to talk about our study and what we found in Massachusetts Medicaid.
Rob Lott:So let's start with just a little bit of background. I just described food as medicine. I'd love your take today. How'd I do? Did I describe it okay?
Rob Lott:And how would you answer someone who asked what exactly is the food as medicine movement?
Kurt Hager:Yeah. You you did a great job. I will say specifically, how we use it and and conceptualize it in the context of this study are programs that are providing healthy food to patients who've been identified by their health care provider, to be food insecure and having a diet related, illness that would be much likely to be, improved through with improved nutrition and getting access to healthy food. So the main connection is a referral from a health care provider who's identified a patient who would benefit from this food, and it's actually, free provision of this healthy food for an extended period of time. So for example, in our studies, many participants receive this food for about six months.
Kurt Hager:So a substantial intervention that's much more than just nutrition education.
Rob Lott:How widespread is this? Are most health care systems engaging in this kind of intervention, or is it still relatively new?
Kurt Hager:It is still relatively new, and I think it's important to kind of ground this conversation today, acknowledging that these programs are unavailable to the vast majority of Americans who might benefit from them. So, there's still it's an emerging concept. There's more studies happening. There's certainly a lot more interest in this at a policy level. But the challenge right now is that historically, these programs have been paid by grants and donations.
Kurt Hager:So often, the studies prior that I've been involved in, for example, have been funded by, let's say, a a food company or a foundation, and they wanted to to pilot kind of a one off program that that lasted six months. But even, you know, if the participants' health improved, by the end of that six months, there really wasn't there was no opportunity to continue the program because because the funding had had run short. So I think that highlights some of the challenges in integrating these into health care in a meaningful way. And that, part of what we'll discuss with our study is, in Massachusetts Medicaid, there was indeed a new pathway for that allowed more sustainable funding for these programs and allowed them to become a more reliable and integrated part of clinical care for select Medicaid members.
Rob Lott:Okay, great. I want to hear a little more about that program, but one more question first is sort of about the evidence. How do we know or rather what do we know about the effectiveness of programs like this? I would say prior to talking about your study and the findings of your study, what was sort of the general consensus about how these programs work with the caveat obviously that there sort of different versions and different kinds of programs that might be effective in different ways or to different degrees?
Kurt Hager:So there's a handful of evidence to suggest that these programs can improve, first and foremost, food insecurity and and dietary intake, we know, food insecurity and suboptimal diet are are associated with, higher rates of diet related chronic illness, higher health care utilization, and higher health care costs. So there's there's a there's a wealth of evidence that these programs can impact those important, measures. There's also increasing evidence that these programs can improve, key clinical outcomes. Their strongest evidence that they can improve markers of cardiometabolic health. So this means things like, blood pressure, hemoglobin a one c, or blood sugar levels among those with diabetes.
Kurt Hager:And there's even some, research that has shown prior to this study, reductions in acute health care utilization, including reductions in hospitalizations and ED visits and even health care costs. But I will say that this evidence is still emerging. There are a lot a lot of these studies have been quasi experimental studies, and we are now just seeing more and more randomized trials that are seeking to confirm the findings from previous studies.
Rob Lott:Great. Well, that's a perfect segue to talk about your research. Can you describe the program that you were studying?
Kurt Hager:So as you mentioned in your intro, Medicaid at a national level, largely does not cover, food as medicine services. So, it cannot directly pay for food to, individuals enrolled in Medicaid. However, there is a pathway that has been used increasingly by states called the eleven fifteen waiver. And at a high level, these waivers allow states to pilot innovative idea in their Medicaid population that they believe is likely to improve health outcomes and also, is cost neutral. So it doesn't add cost to the state or the federal government.
Kurt Hager:And then centers for Medicare and Medicaid services can approve the waivers for up to five years. And so Massachusetts was the first state to get an eleven fifteen waiver that included direct provision of healthy food to select members.
Rob Lott:Once Massachusetts had a waiver, what kind of specific program did they create with that opportunity?
Kurt Hager:One component of Massachusetts eleven fifteen waiver was the creation of the flexible services program. So the flexible services program offered both nutrition and housing supports to high risk Medicaid members. And this is a key thing to keep in mind is that this program was not available to all Medicaid members and was highly targeted and tailored to specific members. So the eligibility criteria for the nutrition program, and this was the focus of our study, members had to be enrolled in a newly created accountable care organization and the creation of those accountable care organizations or ACOs was also a part of the eleven fifteen waiver. They had to be under age 65 plus meet at least one health needs based criteria.
Kurt Hager:And so MassHealth, the Massachusetts Medicaid organization set, a range of health needs based criteria. This included a behavioral health need or a persistent physical medical condition like diabetes or heart failure, need for assistance with activities of daily living. So we can think of this as someone needing help with everyday tasks and living independently, high emergency department use, or a high risk pregnancy. So you can see these are a pretty high risk, high need member population, and plus the final eligibility criteria was, also having food insecurity.
Rob Lott:Okay. Great. So you've got this qualified population. And can you describe a little bit what intervention or what kind of interaction this population had with clinicians or some sort of supportive network, I presume, implementing this food is medicine intervention?
Kurt Hager:Yes. So when MassHealth designed the flexible services program, they designed it in a way to give accountable care organizations a lot of flexibility to create their own programs that they thought would be best suited to meet their members' needs and to choose their own, partnerships with community based organizations in their service area, to to design and implement those programs. So what we found was that there was a wide mix of program designs, and we included all of those in our studies. So you mentioned some of them at the start of the episode. This includes medically tailored meals that are often home delivered to, to people and are tailored by registered dietitians to to meet the very specific medical conditions of individuals.
Kurt Hager:These included produce prescriptions. They were often implemented on electronic cards that people could use to purchase produce of their choice at retail grocery stores. Other program models included food boxes, so kind of like raw ingredients that people could then prepare meals on their own, and others included application assistance to other federal nutrition programs and referrals to food pantries in their in their area.
Rob Lott:Well, I can't wait to hear what you found studying those programs. But first, we're gonna take a quick break. And we're back. I'm here talking with Doctor. Kurt Hager about his study in the April 2025 issue of Health Affairs about food is medicine.
Rob Lott:Kurt, can you tell us a little bit about what you found when studying the programs under Massachusetts Medicaid waiver?
Kurt Hager:Our study focused on acute health care utilization and cost. So the outcomes we were interested in were changes in hospitalizations, emergency department visits, and health care costs. And we also looked at primary care visits as a secondary outcome. Our comparison group included Medicaid members who were eligible for flexible services but did not receive those services. And we looked at the change in, healthcare utilization and costs in the six months prior to starting enrollment in flexible services to the period during which individuals receiving those services.
Kurt Hager:So we and we compared that change from the baseline period to the program period and looked at that difference between the treatment group and the comparison group. And we accounted for, a long list of potential confounders, things like diagnoses, baseline health care utilization, where someone lived, their sociodemographics, and the health systems that were referring them. So after, combining all that data together and comparing the two groups, we found that receiving food from the flexible services program, resulted in a twenty three percent reduction in hospitalizations and a thirteen percent reduction in emergency department visits. And this was among just over 20,000 Medicaid members who received these, food programs from January 2020 to March 2023. So we also looked at health care costs, as I mentioned, and across all of these 20,000 individuals, there was a change in health care costs that favored participants, but it was not statistically significant.
Kurt Hager:But we because this is such a large group and, a long time period of several years. And importantly, as I mentioned, these programs started in January 2020. So this is right before the pandemic hit. So I do wanna give a huge kudos to MassHealth, the accountable care organizations, and the community based organizations for launching this huge program during such a tumultuous time. And so but because of that, we thought it was really important to look at the effects of the program and the immediate outbreak of the COVID nineteen pandemic versus later on, once vaccines are widely available and the economic shutdowns had largely stopped.
Kurt Hager:So what we found is in the first two years of the program in 2020 and 2021, there was actually no change in health care utilization or costs among recipients of the flexible services nutrition programs. However, in years 2022 and 2023, we found even greater reductions, in hospitalizations and ED visits, specifically a forty seven percent reduction in hospitalizations and a twenty one percent reduction in emergency department visits. And during this period, we did see a statistically significant reduction in health care costs of about $1,700 per person when they were receiving their food supports.
Rob Lott:So if I can just drill down on that for a minute, I think, generally, the assumption was that utilization and spending decreased in the early stages of the pandemic broadly.
Kurt Hager:Correct.
Rob Lott:And it sounds like what you're saying is that the reductions here came later so that presumably the cause or the driver of those reductions was not sort of the general pandemic effects, but really more attributable potentially to this program. Is that a fair take?
Kurt Hager:So, you bring up a great point. And if I understand your question correctly, it's, kind of like what it might have been driving this kind of null finding in those early years. Yeah. So we can't state concretely what it was, but I suspect it's a combination of multiple factors. So as you mentioned, people were scared of getting COVID nineteen, and there it was an observed phenomenon across The US that there were actually fewer emergency department visits.
Kurt Hager:People were, you know there was overall less health care utilization except, of course, among those who are getting very sick with COVID nineteen. So just statistically, that does make it, more challenging to detect an effect when there's fewer events occurring. But, also, let's think about that time period. There is such massive disruptions in clinical care, as we mentioned, huge downturns in the economy. And we're talking about a Medicaid population that, on average, was probably much less likely to have jobs in which they could work remote.
Kurt Hager:There was probably large financial upheavals for many of these members. Schools were closed for for quite some time, so increased childcare demands. There were, you know, increases in food costs during this time period. And on the flip side, there also was a really robust federal response to the pandemic, did increase federal nutrition benefits. There were large stimulus checks that went out, tax credits to family, and members in both the treatment group and the comparison group would have received those other large support.
Kurt Hager:So it's also possible there could have been some kind of washing out of the, effects of the program during this time. So it's impossible to know, but I think it's, important to think through these these multiple interconnected factors. And, it was an interesting finding to see in the early years of the program. We didn't see this change in health care utilization, but that it was in fact even larger in a period of greater stability once the worst the pandemic was winding down.
Rob Lott:That's fascinating, and I'm sure it'll be really interesting to continue to track the impact in the years ahead as well as the pandemic is further and further in the rearview mirror. You alluded to some of the other sort of pandemic era benefits, but I wonder if you can say a little more about programs like SNAP and WIC that Medicaid enrollees are also typically or often eligible for. And I'm wondering how you think about the interaction between this program and its benefits and the benefits of nutrition support programs like SNAP and WIC.
Kurt Hager:So within the context of our study, we did not have access to SNAP and WIC enrollment. In a related project we were hoping to do, we were trying to link or trying to see if it was possible to link the SNAP and Medicaid data at the state level. And turns out it's incredibly challenging thing to do, actually, to to merge some of these these programs, that are, you know, run by different state departments. So that proved challenging. So that could be certainly a limitation of our study.
Kurt Hager:We didn't have access to that data. But I think it's, one thing to keep in mind is that, most people in Medicaid would be eligible for SNAP and, of course, you know, pregnant or postpartum women and their newborn children would be eligible for WIC. In Massachusetts, there is a common application for SNAP and Medicaid, so someone can apply for both programs at once. So while we don't know for sure, I would expect there to be similar enrollment rates in SNAP in the treatment group and the comparison group, but we don't we don't know that, for sure because that was data we we didn't have access to.
Rob Lott:I saw that your study included both children and adults. Did you find any differences between those two populations?
Kurt Hager:Yes. We did. So we did another stratified analysis looking at outcomes separately between children and adults. Interestingly, but perhaps not surprisingly, we found no change in health care utilization or costs among children. Children tend to be, you know, healthier overall and have fewer hospitalizations and emergency department visits.
Kurt Hager:But that is not to say these programs aren't, wouldn't be beneficial to childhood development. There are many other outcomes. Like, we know that increased food insecurity, increased dietary quality are so important for childhood development and well-being. We just didn't analyze those within this study. So, that could be something that we look at in the future.
Kurt Hager:For the adults, those results were generally quite similar to the overall finding, but we also looked at the impact of enrollment length. And a really key finding from our study was that among adults who were enrolled for three months or longer, had slightly larger reductions in hospitalizations and ED visits. But most importantly, the also had a reduction in health care costs. And this reduction in health care costs was greater than the cost of paying for the program. So this resulted in about $200 of cost savings per adult member for the Medicaid program.
Kurt Hager:And these costs included the food costs and also the administrative costs at the ACOs and for MassHealth in implementing the program.
Rob Lott:Gotcha. Okay. So a really important finding for potential decisions about future projects and and more widespread implementation, which maybe brings us to the fact that there are some food as medicine skeptics out there, folks who sometimes point to challenges like low levels of adherence, or maybe the unnecessary medicalization of nutrition as reasons to approach these programs with caution. And I'm curious, how your findings from this study maybe inform that debate.
Kurt Hager:Great. Well, both are reasonable critiques, and, I'll start with the adherence comment first. So first, I think we all absolutely who are working in the space should continually work to refine programs to maximize participant engagement and adherence, and that is much more likely to improve health outcomes. I wanna applaud the American Heart Association who's launched a huge effort to, conduct trials that are aimed at improving program implementation and design so that we can begin, really moving forward in an important and meaningful way, to come perfect these programs, to increase health outcomes. Personally, I believe any program that maximizes participant choice and the foods that they receive and maximizes engagement, will be most likely to improve health outcomes and have higher adherence levels.
Kurt Hager:Second, regarding the medicalization, this is also a a a reasonable comment. I would say, you know, to me, there are high food insecurity rates among those with diet related chronic illness in Medicaid. And to me, this reflects that existing federal nutrition programs likely aren't sufficient to adequately address the nutritional needs of these members to prevent, treat, and manage diet related illness. And thus, health care providers and state Medicaid programs are really eager to find additional solutions to improve clinical care, health and well-being, and health care utilization costs as our as our study showed. I've always personally found it interesting that food insecurity is grouped into this bucket of social determinants of health, and I understand, some academics like to debate terminology that food insecurity now reflects food access.
Kurt Hager:But to me, I feel like sometimes we are forgetting that, nutrition is perhaps the most core foundational biological determinant of health. And I believe our results in part reflect that reality and show, this is true and and that these types of programs really can have meaningful impacts on health outcomes as reflected by fewer hospitalizations, emergency department visits, and for, many participants in our study, fewer health care costs as well.
Rob Lott:Okay. What we're talking, in early April. Your paper just came out, and I'm wondering if you've gotten any early feedback. What's the response been, and how are you feeling about it?
Kurt Hager:We are certainly very excited. Our partners, at Massachusetts Medicaid who worked so hard for years to design and implement this program are very pleased with the results. We are also quite encouraged by a very similar study that was published just several weeks ago looking at the eleven fifteen waiver in North Carolina, which also authorized very similar food as medicine programs. This was actually, published in JAMA and led by doctor Seth Berkowitz, who I know was on your podcast recently. And, I'm quite encouraged by very similar findings between the two states and the two studies.
Kurt Hager:So there are a few key differences in the study designs in the program implementation, but largely very similar, program models were in both, studies in states. But Massachusetts, North Carolina are very different state context. And the fact that we now have two, state eleven fifteen Medicaid waivers that are covering these services in slightly different capacities, but are both finding reductions in emergency department visits and, in many cases, reductions in health care costs, to me, is an encouraging finding that, this could be replicated in other states and that there is, in fact, bipartisan support to continue programs like this.
Rob Lott:Well, that's a great encouraging note to end on. Thank you so much, doctor Kurt Hager, for taking the time to chat with us today.
Kurt Hager:Yeah. Thank you so much.
Rob Lott:To our listeners and our readers, if you enjoyed this podcast, please recommend it to a friend, smash that subscribe button and tune in next week. Take care all.
Kurt Hager:Thanks for listening. If you enjoyed today's episode, I hope you'll tell a friend about a health policy.