Covering food and nutrition programs under California’s Medicaid program
What advocates say people in other states can learn from their efforts to support children and families
By Kate Marple

If you had to pick just one place in your community to screen the most children possible for food insecurity and to provide nutritional resources, where would you choose? Children under four aren’t in school yet. Many do not go to daycare or attend places of worship. They do, however, almost all go to the doctor, making it the perfect place to ensure kids get connected with the nutrition they need. And if we treat and fund food as a healthcare intervention, there is an opportunity to improve kids’ short- and long-term health while reducing healthcare costs at the same time.
Children who receive proper early nutrition are less likely to develop a number of physical and behavioral health conditions like diabetes, asthma, iron deficiency, depression, and anxiety. They are also more likely to have better cognitive, communication, gross and fine motor, and social emotional functioning. In other words, the food they eat (or don’t eat) as children affects their health and well-being through adulthood. Healthcare invests a lot of money in more expensive medical interventions to treat the consequences of poor nutrition but does not often invest in food and the nutritional supports that could help prevent disease and hospitalizations. Slowly, that is changing.
California is one of a growing number of states to cover food as part of Medicaid. The breadth and depth of services highlights the opportunity for addressing critical health-related food needs of children and families. However, in many states, including California, a focus on chronic conditions misses a critical opportunity to promote health and prevent disease in children more broadly. The good news is that advocates have an opportunity to not only ensure food services are funded through their state Medicaid agency, but also to ensure that they meet the needs of children and families.
The food and nutrition programs covered by Medicaid in California
Beginning in 2022, Medicaid managed care organizations in California can opt to provide optional Community Supports in lieu of higher-cost services traditionally covered by Medicaid, including a variety of food and nutrition programs. In California, these services are covered by two federal authorities, In Lieu of Services (ILOS) (through a 1915(b) waiver) and an 1115 waiver. The final Community Supports guidance allows health plans to cover meals delivered to the home immediately following a nursing home or hospital discharge, medically tailored meals, and medically-supportive food and nutrition services, such as medically tailored groceries, healthy food vouchers, food pharmacies, and cooking or nutritional education for individuals with a wide range of diagnoses.

The food-based services included under Community Supports and the final implementation guidance followed years of advocacy by different groups across the state. Ceres Community Project and the California Food is Medicine Coalition (CalFIMC) began educating policymakers on the benefits of medically tailored meals long before the state’s Medicaid waiver. In 2017, with help from State Senator Mike McGuire, CalFIMC secured $6 million to conduct a statewide study of medically tailored meals for Medicaid members with congestive heart failure. An additional multi-year grant from a private foundation helped leverage that study to educate health plans, legislators, and the Department of Health Care Services (DHCS), California’s Medicaid agency, about the value of this intervention. The visibility and relationships CalFIMC built laid important groundwork. When DHCS began engaging with stakeholders in 2019 and building out the Community Supports mechanism that would be included in the waiver and ILOS benefits, they specifically included medically tailored meals based on the strength of this previous research and advocacy. CalFIMC agencies worked with DHCS throughout 2020 to help define the implementation guidance in the final waiver.

Elsewhere in 2019, community-based organizations in the Bay Area met informally to talk about different pathways to sustain and expand healthcare-based food and nutrition programs that are critically needed by low-income communities. This group was first inspired to think about Medicaid as a funding pathway after an advocate from North Carolina came to a meeting and shared how his state had included food services into their state’s Medicaid 1115 waiver. While the idea sparked interest immediately, most of these Bay Area CBOs were service providers with little Medicaid expertise. The San Francisco Bay Area Planning and Urban Research Association (SPUR) took the lead on researching what these waivers were, how they worked, and how often they happened. The CBOs formalized their collaboration, first by creating a steering committee and then by expanding statewide into the California Medically Supportive Food & Nutrition (MSF&N) coalition. The coalition urged DHCS to expand coverage beyond medically tailored meals to also include a wider array of medically supportive food and nutrition services. The motivation was simple: people have different health issues, food needs, and food preferences, and advocates wanted flexibility built into the program to better meet the different needs of individuals in California. Now, SPUR, in partnership with the Food as Medicine Collaborative, a food pharmacy provider in San Francisco, runs a statewide community of practice to support CBOs in implementing these services with health plans.
What advocates in other states can learn from California
What advocates learned from the waiver process in California can help champions in other states expand Medicaid coverage for food services that better address the needs of children and families. Cathryn Couch, Chief Executive Officer and Founder of Ceres Community Project and Katie Ettman, Food and Agriculture Senior Policy Manager at SPUR recently shared what went well in California, what they wished they knew when they started, and what they’d do differently. Here is their advice for advocates in other states pursuing this work:

Set aside protected staff time to unpack Medicaid waivers and other opportunities in your state. Medicaid waivers are complicated, and if you are new to this space, it can take a while to get up-to-speed. In the beginning of the MSF&N coalition’s advocacy, Ettman spent almost 20% of her time for several months just unpacking how 1115 waivers and In Lieu of Services worked, what mechanisms other states had used to cover food-based services under Medicaid, and how to engage in the waiver process in California. This research was critical not only for knowing what to ask for but also how to ask for it. Protecting staff time to do this level-setting is critical. Advocates in other states can start by reviewing the Center for Health Law and Policy Innovation’s California case studies, as well as reading through the publicly available Medicaid waivers in North Carolina, Massachusetts, New York, and California to better understand how they structured food interventions. Then find out who your state’s Medicaid authority is and if/when a waiver is being created or renewed in your state.

Involve all voices in the advocacy. While preparing a position paper for DHCS, MSF&N quickly expanded to include groups from across California who could speak to the needs, resources, and programs in other regions. The coalition made sure to convene people and organizations with different perspectives, including: program providers who could speak to the reality of service delivery and what a specific program looks like on the ground in a specific community, clinicians who could speak to the frustration of being asked to screen patients for food insecurity without having food resources they can prescribe when needed, representatives from health plans who could share nuts and bolts about implementation design, and advocacy experts who could inform engagement efforts. In the end, more than 100 organizations signed onto the position paper, including CBOs, medical societies, and health plans, strengthening both the recommendations themselves and the credibility of the position paper.

Leverage data. The 2017 statewide study on medically tailored meals played a significant role in DHCS’ decision to initially include it as a Community Support. Couch stressed that peer-reviewed research as well as examples of how other states have successfully incorporated food services into Medicaid were powerful advocacy tools in California. Ettman echoed this sentiment, stressing that one-pagers summarizing the data on different food interventions were persuasive tools in SPUR’s conversations with policymakers. Aspen Institute’s Food as Medicine Research Plan includes a comprehensive summary of peer-reviewed published data on a range of food is medicine interventions.

Cultivate relationships and show up everywhere.
This is systems-change work. It’s about building a long-term partnership between health care and food, and that won’t happen overnight. When advocating for Medicaid food interventions, advocates should use every opportunity and tool at their disposal to educate policymakers, build relationships, and raise the visibility of their work. Go to public forums hosted by your Medicaid agency, and not just once; keep showing up. Provide recommendations on the waiver during the public comment period. Meet with staff from your Medicaid agency. Build relationships with legislators who will advocate your position on your behalf. MFS&N and CalFIMC used all these techniques, including getting four legislators to send a letter to DHCS calling out the potential for cost savings and improved health outcomes of medically supportive food and nutrition. And don’t wait until a waiver is being drafted in your state to get involved. Start building relationships with your state Medicaid agency and policymakers now to raise the profile of your organization and the impact of food interventions on health. As Ceres and CalFIMC proved, it’s a lot easier to leverage a Medicaid waiver opportunity if your organization is already a known and respected entity among decision-makers.

Build-in options and flexibility. Different people and families have different nutritional needs based on disease and acuity, age, living situation, culture, preference, ability, and allergies. Clinicians should have the flexibility to choose an intervention that matches the need. Ettman emphasized that covering an array of food interventions is critical for helping match the right type and level of intervention to different people with different health conditions. It is also important for making services accessible. States should advocate for language and guidance that includes multiple food interventions and a range of service providers. This also broadens the number and type of organizations who may support this policy change. To support families, it is critical to include and advocate for programs that provide food for entire households since households are likely to share their food resources. Additionally, advocates should champion broad eligibility criteria for services so that interventions can be delivered not only to children diagnosed with a chronic condition, but also to children who have been identified as at-risk for that condition.

Define each intervention clearly and specifically in the implementation guidance. While flexibility and options are important, Couch also stressed that if you don’t clearly define each intervention–what it looks like, how much it costs, and its clinical appropriateness—it becomes nearly impossible both to evaluate the success of each intervention and to set rates accurately and equitably. For example, while California’s Community Supports guidance allows for both home-delivered meals after hospital discharge and for medically tailored meals to help treat specific chronic conditions, the final language doesn’t distinguish between the two different programs and that has negative consequences for service providers. In this case, DCHS used rates from Meals on Wheels to set the pricing guidance for all meal delivery services, including medically tailored meals, the latter of which is a more complex and intensive program. In addition, the rates don’t account for the significant increase in costly administrative processes to participate in Medicaid billing. As a result, the rates are set well below the actual cost of the intervention. This makes it difficult to provide the service and can undermine the long-term work of community-based organizations. This need to capture, define, and account for rates exists across all types of food interventions, and states should also think carefully about differences in the cost of services in rural and urban areas. Couch said CalFIMC assumed that their previous advocacy had created a deeper and more nuanced understanding for medically tailored meals. She wishes they had focused more on educating policymakers around the differences between programs when the California guidance was being set and says it’s critical that advocates in other states make these distinctions and also that CBOs are able to articulate the value proposition of their work. However, advocates should also be mindful that specificity can also carry risk. For example, creating a line item for lower acuity interventions may make it more difficult to get them included as an approved service.

Advocate for the maximum amount of funding possible for infrastructure-building. It takes considerable knowledge, labor, and funding for a CBO to build the necessary infrastructure to contract with a health plan. It can often take a year just to get set-up, and CBOs need training and technical assistance during the transition. Both Couch and Ettman stressed that this infrastructure-building can be a barrier to entry for CBOs, many of whom opt out of working with Medicaid because of it. It’s an equity issue too, Couch noted, since it’s often small, BIPOC-led organizations that cannot make the transition. Under 1115 waivers, states have the option to spend up to 15% of waiver costs (which are capped at 3% of total Medicaid spend) on infrastructure. California uses this funding to support technical assistance, collaborative planning, and implementation efforts. This funding is also used to specifically help CBOs build the knowledge, staffing, and technological capacity to contract with health plans. It is important for advocates in other states to ask that these funds be maximized and to leverage training and technical assistance resources.

Forty percent of children are enrolled in Medicaid at birth and disproportionately come from families with low-incomes. Health care generally, and Medicaid specifically, offers one of the best leverage points for making sure kids connect with the food and nutrition resources that will help them be healthy now and in the future. As California is proving, the waiver process presents an enormous opportunity to make food a priority for health care, and food advocates have a critical role to play in ensuring not only that this happens, but that services are designed to meet the needs of children and families.