Access to Healthy Foods: Social Determinants of ISSUE BRIEF

MAY 2018

KEY TAKEAWAYS

An estimated 1 in 8 Americans was food insecure in 2016. Food insecure households spend 45 percent more on medical care than people in food-secure households.

Successful, sustainable interventions include community- based support with programs that focus on increasing access and promoting behavior changes related to food preparation.

From food delivery services to mobile food pantries, health insurance providers are investing in innovative models to increase access to nutritious foods and ultimately, improve outcomes for their members.

Social Determinants of Health and Access to Healthy Foods

Background

A person’s health is influenced by many DEFINITIONS factors, including housing, education, employment, and access to healthy food. Food Insecurity These factors, sometimes referred to as the The uncertain ability to obtain nutritious social determinants or social influencers of foods because of access and/or financial health, are defined by the conditions and limitations to grocery stores, markets, etc. environment in which people are born, grow, live, work, and age. Food as Medicine Providing medically tailored foods to high-risk A lifestyle of healthy foods and exercise helps patients for prevention and/or treatment of a prevent the onset of chronic health conditions. specific health care condition (e.g., a low However, millions of Americans have limited sodium for patients with ). access to foods that promote a healthy lifestyle. As a result, they are more likely to suffer from chronic conditions, such as hypertension and diabetes1.

Limited access to healthy food can be driven Market forces can also play an important role, by different factors: with grocers, restaurant owners, and fast food chains all contributing to the landscape of food 1. Income, where people are not able to availability for communities. For example, the afford food, even though nutritious food U.S. Department of Agriculture defines a food may be available close by. desert as a low-income area where a substantial number of residents has limited 2. Accessibility, where people may be able access to a or a large grocery to afford healthy food, but it may not be store2. Recently, experts have also begun physically available to them (e.g., citing food swamps, or areas with a high- people with physical and/or cognitive density of stores selling high-calorie fast disabilities, lack of transportation, foods3, as a similarly quantifiable region where substandard kitchen not equipped to access to healthy foods may be limited. prepare healthy foods, etc.) As part of their commitment to improve 3. Cultural, where people can afford individual and population health, many healthy food that is geographically insurance providers offer coverage for accessible, but they need help to learn nutritional counseling, where a registered how to identify and prepare nutritious dietician works directly with patients to improve meals. their dietary intake. However, even with nutritional counselors and patient education efforts, some members may still have difficulty accessing healthy foods. Facing this challenge, many insurance providers and hospitals have launched initiatives to bring healthy foods to specific populations of patients who are

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Social Determinants of Health and Access to Healthy Foods

chronically ill or face barriers to accessing Food Insecurity Resources and nutritious foods. Tools • Food insecurity initiatives typically focus on the uncertain ability to obtain Federal, state, and local government nutritious foods because of access stakeholders recognize the impact of food and/or financial limitations to grocery insecurity and have developed strategies to stores, markets, etc. Typical address these issues. Several programs and interventions may include providing tools are available to support these efforts: vouchers for families to purchase healthy foods, developing new models • Supplemental Assistance of grocery stores, or providing meal Program (SNAP): Administered by the delivery programs. USDA’s Food and Nutrition Service (FNS), SNAP offers nutrition assistance • Building on these interventions, food as to eligible, low-income individuals and medicine initiatives programs focus on families. FNS works through its interventions tailored for high-risk nationwide network of field offices to patients for prevention and/or treatment monitor those stores participating in of a specific health care condition (e.g., SNAP. a for patients with hypertension). • Food Desert Locater: USDA has a web-based mapping tool to pinpoint the location of food deserts around the Research continues to emerge on the country and provide census data to effectiveness of these programs. In one study, describe population characteristics of researchers found that seniors who residents living in these areas. participated in a medically tailored meal delivery program had fewer emergency • Women, Infants, and Children (WIC): department visits, hospital admissions, and USDA’s Special Supplemental Nutrition emergency transportation trips, compared to Program for WIC provides federal grants those who did not participate. Further, medical to states for nutrition education, spending for those in the medically tailored supplemental foods, and health referrals meal delivery program decreased about $570 for low-income pregnant, breastfeeding, per month per person4. and non-breastfeeding postpartum

women, and to infants and children up Both food insecurity and food as medicine to age five who are found to be at programs have the same goal - increasing nutritional risk. patients’ access to nutritious foods that promote a healthy lifestyle. These initiatives • Medicaid Programs: work best when community leaders and organizations, doctors and hospitals, insurance o Medicaid Home and providers, and others work together to bring Community-Based Waivers together local resources, support local needs, (HCBS): HCBS waivers allow and work toward having a real impact on local states to provide Medicaid health. services that help those

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Social Determinants of Health and Access to Healthy Foods

individuals who are at risk of children that may be impacted by food being placed in long-term care insecurity issues. If either (or both) facilities stay in their homes. questions are answered with “Often Many states have extended their True” or “Sometimes True,” the child waivers to include nutrition and family are considered at risk for services (e.g., home-delivered food insecurity: meals, nutrition counseling, etc.). o Question 1: "Within the past 12 months we worried whether our o Medicaid Managed Long-Term food would run out before we got Services and Supports money to buy more." (MLTSS) Programs: o Question 2: "Within the past 12 Increasingly, states are using months the food we bought just MLTSS programs to expand didn't last and we didn't have beneficiary access to HCBS. money to get more." Health insurance providers operating MLTSS programs • AARP Resource Guide and Toolkit: coordinate all long-term medical Intended for use by health care and behavioral health needs, providers, this guide seeks to address which may include nutritional screening and referrals in services, in return for a capitation primary care settings serving older adult payment. patients.

• Medicare Advantage: Starting in 2019, • Find a Food Bank or Pantry Locator: CMS is expanding the scope of the Developed by Feeding America, this “primarily health related” supplemental locator connects users with a natiowide benefit standard to include additional database of food pantries and meal items and services if recommended by a programs. licensed medical professional. The item or service must directly impact an Health Plan Strategies for enrollee’s health care needs and meet specific criteria. The list of allowable Improving Access to Healthy Foods supplemental benefits includes Adult Day Care Services, and specifically lists Health insurance providers continuously that meals that are ancillary to primarily innovate new programs to improve access to health related services may also be healthy and nutritious foods. These efforts provided. reflect the growing trend toward a “whole person” approach to health care that is more Beyond government, other health care holistic, effectively addressing all of a stakeholders have also developed tools to help member’s health conditions. health care providers identify food insecurity for patients in clinical settings: Examples of health plan programs are

described below. • American Academy of Pediatrics (AAP) Food Insecurity Screening Blue Cross Blue Shield of Massachusetts Tool: This two-question screening tool (BCBSMA) Foundation: BCBSMA is the can help providers quickly identify largest insurer in Massachusetts with more

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Social Determinants of Health and Access to Healthy Foods

than 2.5 million members. The BCBSMA - Sustained engagement and improved Foundation, which operates separately from clinical outcomes for three+ months; the insurance plan, provides grants to nonprofit - A decrease of 18 percent or more from organizations, community health centers, and baseline to current for other clinical hospital programs focusing on low-income metrics including LDL, triglycerides, individuals and populations. weight, and blood pressure; - Patients asked for additional classes Recently, the Foundation gave a grant to including tobacco cessation, walking Community Servings to create a “Food as programs, and class reunions; Medicine” State Plan for Massachusetts. The - Increased percentage of care gaps plan will include analysis of the current closed with patients enrolled in the landscape of food as medicine interventions, program; and provide recommendations to policymakers, and - Demonstrated financial savings. identify opportunities to increase access to such interventions, while coordinating efforts to Health Care Service Corporation (HCSC): best support low-income people with chronic Launched in 2011, HCSC’s Healthy Kids, diseases. Healthy Families® initiative invests in and partners with nonprofit organizations to Geisinger Health Plan: An integrated health improve the health and wellness of children care system operating in Pennsylvania, and families in their communities. The initiative Geisinger Health Plan wanted to design a targets sustainable and measurable programs program targeting patients with type 2 that focus on increasing physical activity, (HBAIC levels greater than 8), after research preventing and managing disease, promoting showed that 1 in 4 of type 2 diabetes patients safe environments, and supporting food are food insecure. Geisinger modified its sources. electronic health records (EHR) to include a screening tool to identify patients who are food HCSC is committed to fighting hunger and food insecure. These patients receive a insecurity for children and their families. Local “prescription” for Geisinger’s Fresh Food partnerships have been critical to HCSC’s Pharmacy. success. HCSC worked with the Chicago Botanic Gardens and Lawndale Christina The Fresh Food Pharmacy, located in Health Center to increase the availability of Northumberland County, provides access to a healthy foods in food-insecure communities. food pantry stocked with healthy foods, and The project trained 250 individuals in increases access to diabetes self-management sustainable and engaged courses, registered dieticians, health managers physicians in a nutrition education VeggieRx (RN), health coaches, and community health program. In another Illinois program, HCSC workers. Northumberland County was teamed up with the Sweet Water Foundation to identified as the location after research showed engage youth to transform underutilized that 12 percent of residents over the age of 20 spaces into sustainable community assets that have diabetes and 1 in 3 residents is produce locally-grown food and support considered food insecure. Geisinger’s nutritional education programs. In Oklahoma, investment has paid off: HCSC partnered with Global Gardens to improve nutritional health for underserved - Average reduction in hba1c of two students by engaging their families in organic points; gardening and cooking.

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Social Determinants of Health and Access to Healthy Foods

As a result of these and other partnerships, in 84 percent of customers prepare healthier 2017 HCSC distributed more than 2.2 million foods and snacks. pounds of food across five states, benefitting nearly 698,000 adults and children. To learn Working with Community Partners more HCSC’s Social Responsibility efforts, click here. to Improve Food Insecurity

UCare: The Minnesota-based health insurer In 2016, more than 28 million adults (11.5 UCare partnered with the Amherst H. Wilder percent of all adults) and nearly 13 million Foundation to launch the Twin Cities Mobile children (17.5 percent of all children) lived in Market Initiative in 2014. The “grocery store on food-insecure households.5 wheels” model sells healthy foods at below- Health insurance providers recognize the market prices to low-income areas in importance of addressing the social Minnesota’s St. Paul and Minneapolis determinants of health to prevent and treat neighborhoods, deemed the fifth largest food health care conditions. A lifestyle of healthy desert in the United States. The project began foods and exercise helps prevent chronic by first transforming an unused Metro Transit conditions, but access to nutritious foods can bus into a mobile market to deliver healthy be limited. Health insurance providers are foods. The bus’s route travels consistently to committed to improving these conditions for more than 30 locations at scheduled times families and communities. They continue to (once/week). In addition to UCare members, innovate to address these needs. From food the Mobile Market can be accessed by anyone delivery services to mobile food pantries, in the community. health plans are designing creative models to help improve access to healthy foods. Partnering with community organizations to provide customers with cooking Collaboration is key. Successful, sustainable demonstrations, culturally appropriate foods, interventions include community-based and nutritional education, Wilder recently support, programs focused on behavior expanded the Mobile Market to also serve as a changes related to food preparation, and at- mobile health screening unit, with individuals your-door service that meets members in their receiving three free grocery items for homes and communities. As a part of their participating in selected health screenings. In unwavering commitment to improve the health 2017, the Twin Cities Mobile Market had of all Americans, health insurance providers 18,515 transactions, a 17 percent increase continue to collaborate across the public and from their transactions in 2016. In their most private sector to improve access to healthy, recent customer survey, 89 percent of its nutritious foods. customers buy more fruits and vegetables and

Endnotes

1 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2806885/ 2 https://www.acf.hhs.gov/ocs/programs/community-economic-development/healthy-food-financing 3 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5708005/ 4 https://www.healthaffairs.org/doi/10.1377/hlthaff.2017.0999

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