Dan Gorenstein
Many of us are thinking about food this week. Personally, I’m psyched to barbecue two turkeys with my brothers-in-law and make my mom’s cranberry sauce. But for many who work in health care, that focus on food won’t end after the holidays. It’s going to keep coming up in boardrooms and doctor’s offices across America.

Dr. Mandy Cohen
Right. We didn’t wake up a few years ago and go, ‘Oh, my gosh. Food matters to your health.’ Like, I think we know that. And evidence has shown that over and over and over.

Dan Gorenstein
Research shows food insecurity — where people struggle to get enough nutritious food — is associated with increased rates of heart disease, diabetes, depression and asthma. And for people with certain medical conditions, not getting the right foods can have disastrous consequences. Add it up and a lack of healthy food means billions a year in avoidable health care spending. When food is a form of medicine, should insurers cover it? From the Annenberg Studio at the University of Pennsylvania, I’m Dan Gorenstein. And this is Tradeoffs.

Today on the show, how doctors, hospitals and even some insurance companies are trying to improve health through better eating. Hospitals from Minneapolis to Toledo to Nashville have food pharmacies on site where patients can fill prescriptions from their doctors.

News tape
Assistance like the food pharmacy is really important in middle Tennessee. In Davidson County, there are nearly 100,000 residents dealing with food insecurity.

Dan Gorenstein
In cities like Washington, D.C. and San Francisco, doctors give patients vouchers for grocery stores and farmers markets. There are even some hospitals that run their own organic gardens. Some may think that the health care system providing healthy food to sick and hungry people is the obvious and moral thing to do. But for many of these programs, the data, the actual evidence on their ability to improve our health is limited. There is one exception: medically tailored meals.

Bouba Dieme
So welcome to my house. This is Desirée.

Dan Gorenstein
Bouba Dieme and his wife Desirée Allen share a tight two bedroom apartment with their 5-year-old son and 16-month-old twins.

Bouba Dieme
Now they’re exhausted. (crying noises) 

Dan Gorenstein
Bouba and Desirée live a hectic life. They work full time.

Desirée Allen
We have three kids, and we’re living in Boston. So that means we have a lot of pressures. I mean, we’re trying to like make it every month, like pay rent, figure out child care.

Dan Gorenstein
And then there’s Bouba’s heart.

Bouba Dieme
Essentially, my heart muscle never formed at birth. So it’s a heart defect. What that did is that over the years, the heart got bigger and bigger, and it couldn’t pump enough blood. So I ended up having heart failure.

Dan Gorenstein
Today, the 33 year old waits. Bouba, who stands 6-8 and looks like he’s a starting forward, for the Boston Celtics, needs a new heart. He’s in line for a transplant, and he has to stay healthy or risk getting kicked off the waiting list. But this young family has struggled to feed Bouba so he can be as healthy as he needs to be.

Desirée Allen
If you ever look at the sodium content of Ragu, that’s his like sodium limit for the day.

Bouba Dieme
As a cardiac patient, when you’re really sick, your margin is very small. So a small difference in the salt amount, for instance, can put you to bed or make you sick, very sick. So it’s a big factor.

Dan Gorenstein
At the beginning of the year, Bouba started receiving medically tailored meals as part of his treatment.

David Waters
Medically tailored meals are controlling your diet in the midst of a health crisis. It’s really about bringing them exactly what their doctor and their health care team need them to eat.

Dan Gorenstein
David Waters is CEO of Community Servings. It’s the organization that provides medically tailored meals to Bouba and more than 2,000 other people across Massachusetts.

David Waters
When we show up at their house, we’re bringing them a bag that includes lunch, dinner and a snack for five days.

Bouba Dieme
Today, we have split pea and carrot soup. That’s one of my favorites.

David Waters
Five homemade soups and salads for lunch.

Bouba Dieme
Egg salad, we have a number of salads.

David Waters
Yogurt, fresh fruit and cereal for snacks.

Bouba Dieme
Today I have Cheerios.

David Waters
And a quart of milk.

Dan Gorenstein
Medically tailored meals date back to the late 80s, a response to the HIV/AIDS crisis.

News tape
Good evening. The disease has already claimed more victims than Legionnaires disease and toxic shock syndrome combined.

David Waters
Well, one of the things that most people don’t know about the history of HIV and AIDS is that in the early years, the majority of people were actually dying of malnutrition.

News tape
More than 800 cases nationwide, 300 plus of those fatal. And every day, three more cases are identified.

David Waters
It’s what’s called AIDS wasting syndrome. So food was the only medicine, and it was, in those days, literally about as many calories as possible.

Dan Gorenstein
Over the last 30 years, medically tailored meals have evolved. Community Servings, for example, has gone from treating men with HIV/AIDS to providing food for 35 different conditions, including diabetes, heart failure and cancer.

David Waters
Typically, a patient is referred to us through their care manager or their doctor, nurse, social worker. From that, we determine if they’re sick enough to need our meals program. The problem is that programs like Community Servings can’t raise the money fast enough to meet the demand. We’re always faced with a waiting list of sick, hungry patients who need our meals and we don’t have the resources.

Dan Gorenstein
So, David, a lot of the money to go to your program has come from philanthropic dollars and federal grants. Now you’ve actually managed to persuade a few insurers like Blue Cross Blue Shield of Massachusetts to start buying in. How did you convince insurers to actually pay for food?

David Waters
When Community Servings first went to the health care community and said, ‘You should be paying us to feed your patients,’ they rightfully so said, ‘Well, we understand it on an emotional level or an intellectual level, but on a financial level, we would need to see, you know, a proven return on investment.’ And rather than be intimidated by that, Community Servings went out and found an exceptional researcher whose field is food insecurity and health and partnered with him, initially in a very small study and then two larger, more ambitious studies that have now been published in peer-reviewed journals.

Dan Gorenstein
And what was the case that you made? What was the evidence that you said, ‘Look, if you give certain patients medically tailored meals, you’re going to be able to, 1) improve their health and 2) you might even actually be able to save money.'”

David Waters
We definitely think you can save money. Our research published this spring in JAMA Internal Medicine with 800 patients, saw a 16% reduction in overall health care costs per member per month net of the cost of meals.

Dan Gorenstein
That study was done by Seth Berkowitz at the University of North Carolina. He compared people who got Community Servings meals to very similar patients who didn’t and found that these meals cut hospital visits, ambulance rides and trips to the ER nearly in half. The results have made an impression on the skeptics.

David Waters
We’re hearing from a number of health care organizations around the country where the term medically tailored meals is familiar to them, which it wasn’t only two or three years ago. I think that we expect that 50% of our patients will be fed through their health insurance within the next five years.

Dan Gorenstein
That’s a pretty bullish estimate. Why are you so confident in that?

David Waters
Well, right now, it’s about 20%, Dan, so we’ve only been doing this for three years and it’s still a relatively new concept. And I want to caution that when we talk about providing medically tailored meals, it’s never that we think health care should feed everybody. For a small sliver of the population, those are the folks where it would make sense on a financial level to be feeding them.

Dan Gorenstein
Bottom line, medically tailored meals are pretty expensive intervention, right? We’re talking 20 to 60 bucks a day per patient. So what’s the case, David, what’s the argument that you’re going to make why health insurers and health care providers should actually be footing the bill for this?

David Waters
I would challenge the assumption that this is expensive. I think if you look at other government feeding programs, whether they’re Meals on Wheels programs for seniors or school nutrition programs. Yes, medically tailored meals are expensive, but compared to any other health care intervention, they’re cheap. One night in the hospital is, you know, $4,000-$5,000. The prescriptions that we take, it wouldn’t be unusual to have an expensive treatment that cost $25 a day.

Dan Gorenstein
The case people like David are making is starting to land with some payers like Dr. Mandy Cohen. Mandy is the Secretary of Health and Human Services for North Carolina and oversees the state’s Medicaid program that primarily provides care to low-income residents and people with disabilities. The federal government has granted North Carolina a waiver to spend $650 million to experiment with paying for programs with some research behind them, including housing assistance, help with transportation and food. Mandy understands how foundational food as medicine actually can be.

Dr. Mandy Cohen
I saw a patient when I was training in Boston. She had insurance, she was a full-time student, and she was having some medical symptoms. And based on those symptoms, I ran a lot of tests. Blood tests were normal, the CT scans were normal. And I was talking to my mentor to say, ‘Well, what should I do next?’ The nurse who checked in the patient heard us debating this and she said, ‘You know, I think you need to ask your patient if she has enough to eat.’ That was an incredibly horrible moment as a doctor because I was asking her questions about her past medical history and her medications. And I didn’t ask her a fundamental question about did she have enough to eat. But I spent a lot of dollars, a lot of health care dollars, billed to her insurance company on blood tests and CT scans that didn’t need to get spent. If I had only gotten to the root of the issue, which was she did not have enough to eat.

Dan Gorenstein
Thank you, Mandy. It’s clear, as you just said, as your story shows, food is critical for our health. In your mind, when it comes to these medically tailored meals, how persuaded are you that they can both lower costs and improve care?

Dr. Mandy Cohen
I think there is some benefit for certain populations, but I don’t want to say that they’re the only thing out there. And I encourage you to be broader in how we think about what are the interventions we can do for folks that are food insecure. If you look at the data around SNAP enrollment, it works.

Dan Gorenstein
SNAP is what food stamps are now called.

Dr. Mandy Cohen
Yeah, so it decreases Medicare and Medicaid costs. It decreases hospitalization use. It increases school performance for our kids. Right? That matters. Those are the tangible benefits of enrolling in SNAP. I think medically tailored meals has its own evidence base. It doesn’t mean they have to trade off against each other.

Dan Gorenstein
And that’s exactly what your pilot program in North Carolina is doing, right? Testing out several different interventions. So when it comes to medically tailored meals, who do you think is the most likely patient?

Dr. Mandy Cohen
My expectation is that when we pay for medically tailored meals, it is going to be a very, very small subset of patients. It’s going to be for those that are homebound, more medically complex and have a food-related health need like diabetes or something where food is very tailored. But I think this is exactly what our study is meant to suss out.

Dan Gorenstein
So what you’re talking about right now is really important, right? Yes, there are people who need SNAP benefits. They need to get enrolled in that program. There are other people who would really benefit from some sort of like food box, some donation box. And then you’ve got the people who really are better suited for a medically tailored meal intervention. But I think the really tricky part, Mandy, is probably figuring out who is who. So what steps are you guys going to take to really try to like figure that out and like get into the weeds of understanding people like this?

Dr. Mandy Cohen
You are 100% right. That is the hard part here is to understand the signal to noise. And as a public servant and as a steward of taxpayer dollars, I need to make sure that we are using our dollars as efficiently as we move forward here. We know that food interventions matter towards health. So we want to invest here. The question is, who needs the most expensive kind of intervention like a medically tailored meal or who needs help enrolling in an existing program like SNAP, which is a less expensive intervention? And I think our job is to understand and learn through our pilot here in North Carolina what populations need, what kind of intervention, so we can use our resources most judiciously.

Dan Gorenstein
So you’re talking about the need to be a good steward of the taxpayer dollar. And you and your staff spend a lot of time talking about the need for some sort of real time program evaluation and moving on from the stuff that doesn’t work. It seems to me that it’s pretty possible that some people who get these meals, the food could just like pile up in the fridge or somebody might want to share the food with other people who live in the household. So as you guys conduct your assessments, how are you going to make sure that the food is getting into the hands of the people who really need it most?

Dr. Mandy Cohen
It’s a great question, and those are some of the things that we’re trying to infuse into the design of the program as we go, which is why we’re probably going to put more emphasis on meals that are delivered by humans that actually then interact with that person to see and actually walk into their home and see is it piling up in the fridge and actually have the conversation, you know, is this food enough for you or are you sharing it with your grandkids? Right. And like actually have those honest conversations with folks. And I would say that just because these issues are complicated and hard — and they are — doesn’t mean we shouldn’t take those first steps forward to try to detangle some of these hard issues and learn what we can. So we are going to have to learn and say, no, that didn’t work. We’re not going to be able to keep investing in that. We may have to shut that that intervention down and move on to something else that is is showing more promise as we evaluate.

Dan Gorenstein
North Carolina is not the only place that’s experimenting with medically tailored meals. You’ve got a number of states — Texas, Tennessee, California — they’ve all got some sort of level of pilot program up and running. Are we at a tipping point, Mandy? Like if we start to see some real positive results here, do you think that this could start to really get adopted widely around the country? And not for everybody, right, not all patients, but at least some, this subset of patients that we’ve been talking about.

Dr. Mandy Cohen
I do think that we have a fair amount of evidence still to develop in the near-term. But I do think over the medium- to long-term, you are going to see more food interventions, whether that’s medically tailored meals or other kinds of interventions, be part of the suite of activities that our health care dollars pay for because we want our health care dollars to pay for health. And we know that intervening around food drives us closer to getting health.

Dan Gorenstein
What you just said, that food drives us closer to getting health, it may sound intuitive, but it’s actually a pretty radical idea. At least in this country, right? Hospitals and insurers have not historically paid for food, like actually paid for food.

Dr. Mandy Cohen
I think as we mature the evidence of what interventions to what folks that we are going to see more payers — more insurance companies, more payers from the state perspective — actually use their health care dollars to pay for things in the food space because it improves health and reduce costs.

Dan Gorenstein
As you think about the rollout of this program, Mandy, is this sort of on a personal level, is part of it an opportunity to make amends for the patient that you treated so long ago back in Boston?

Dr. Mandy Cohen
Absolutely. You know, I spent a lot of health care dollars, but didn’t ask her a fundamental question about her health, which is do you have enough food to eat? And I want to use all my power that I can to make sure that we don’t make that mistake again. And I don’t think that was because I was a bad doctor or because I didn’t care. I didn’t have the right system around me to ask those questions routinely and to be able to connect her to resources. And so we’re gonna be trying to build that system here in North Carolina. And it’s not easy and it’s going to take time. And there are certainly thorny issues that we’ll work through as we unravel some of these long-siloed programs. But we know what we’re aiming for, which is health.

Dan Gorenstein
Mandy Cohen, thank you very much for taking time to talk to us.

Dr. Mandy Cohen
Thank you, Dan.

Dan Gorenstein
If this current crop of projects like in North Carolina deliver better care and save money, we may soon see insurance companies do something at scale that was hard to imagine just 10 years ago: pay for people’s meals. But that’s likely for just a tiny number of patients. When it comes to the 14 million people who experience food insecurity, the future is murkier. Yes, some hospitals and insurers supporting SNAP sign-ups, food pharmacies and organic gardens is a sign that food is getting more attention. But we’re a long way from the day where these other food programs are going to be prescribed and paid for like medicine.

If you want to check out the research on medically tailored meals and other food as medicine programs for yourself, you can do that at tradeoffs.org. I’m Dan Gorenstein. This is Tradeoffs and Happy Thanksgiving.