An Apple a Day: Food Can Be Medicine for Low-Income Californians Under Health Care Plans

Originally published by Capital & Main on June 29, 2023, by George B. Sánchez-Tello.

In a drab gray government room in Sacramento, Rosalina Michel nervously sat in an avocado green chair. She had traveled more than 360 miles to speak at this hearing with elected officials to share her fear of her pre-diabetes diagnosis. Then she recalled how her doctor offered a simple solution. 

“I didn’t want to be a diabetic. I did not want to be on insulin all my life. I wanted to see my grandkids grow,” said Michel, a Los Angeles native and San Fernando resident. Michel receives health coverage through Medi-Cal, the state’s health care program for those with limited income. Michel’s doctor had referred her to a pilot program that, through Medi-Cal, prescribes and pays for food as medicine.

 
Reading from a written statement, Michel presented professionally in her blue blazer, salmon blouse and horn-rimmed glasses. But her voice revealed the anxiety of speaking before total strangers — and betrayed the emotional vulnerability of someone admitting the program allowed her to purchase fruits and vegetables once too expensive. Her voice again cracked as she described newfound mobility after her blood sugar level stabilized.

“My body feels different. I feel better,” she told the committee. “I believe if I didn’t make these changes in what I was eating I would be diabetic now.”

California lawmakers can help more Medi-Cal patients, like Michel, by broadening eligibility for the food medicine pilot program and extending beyond its 2027 end date. Yet this past spring, assemblymembers killed the opportunity in a quiet acquiescence to cost concerns. But advocates say there’s still time to line up state funds to get food to vulnerable Californians suffering chronic disease and illness.   

“Too many Californians, particularly Californians of color, are living with largely preventable chronic conditions. I would rather have an apple over angioplasty,” said Assemblymember Mia Bonta (D-Oakland) via e-mail. She proposed Assembly Bill 1644 this past spring. “Food and nutrition are a fundamental part of preventing and treating chronic conditions, and can significantly improve a patient’s quality of life and health status while also reducing health care costs.”

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Wholesome food can be healing. Healthy food can be medicinal. Among advocates, researchers and lawmakers, the concept is known as medically supportive food and nutrition, or MSF&N. 

A nationwide study found that a subsidy of as little as 30% on costs for fruits and vegetables can lower the risk of cardiovascular diseases and diabetes among people with Medicaid and Medicare, lengthen life and lower health care costs. 

Up and down the state, California patients have achieved the benefits of food as medicine. Since at least 2021, more than 123 organizations across California, including nonprofits, government agencies and health care providers, provide food, food services or programs, according to a report by the San Francisco Bay Area Planning and Urban Research Association (SPUR). However, without guaranteed funding — the food has been paid for through grants and donors — those programs will end. More concerning, the statewide potential for all Medi-Cal patients cannot be realized. 

“We need sustainable funding for food-based interventions,” said Katie Ettman, food and agriculture senior policy manager for SPUR. 

In late 2021, the federal government allowed California to launch a five-year MSF&N pilot program through Medi-Cal, the state’s health care system for California’s most vulnerable residents. By directing government reimbursement, MSF&N no longer depended on philanthropic goodwill. Since 2022, some health plans have offered MSF&N. 

Food as medicine seems obvious. While no meal is a panacea, the virtues of fruits and vegetables are impressed upon children and young people everywhere. In the United States, people grow up hearing, “An apple a day keeps the doctor away.” But what if you can’t afford that apple? California offers six ways that patients can get food as medicine either as groceries or meals. 

Patients can receive what are called medically tailored meals, food prescribed by a registered dietitian for a specific medical diagnosis, such as diabetes, preeclampsia or risk of stroke; or medically supportive meals that follow federal dietary guidelines and meet general health recommendations. 

In addition, patients can receive what are called medically tailored groceries, or medically supportive groceries. Patients can visit a food pharmacy, essentially a pantry with healthy food located within health care settings. Lastly, patients can get a produce prescription such as Michel received, which allows patients with diet-related health risks to use vouchers to purchase food with no added fats, sugars or salt. 

In addition, MSF&N programs offer patients cooking classes and education on how to prepare the new foods to help with the condition they are being treated for. 

All of this is available today for MediCal patients, but only if their health plan has selected, or opted into, the treatment program. That shortcoming is addressed in the proposed California law that lawmakers failed to pass: At least three of the six options for groceries and meals would be available to all MediCal patients, everywhere. 

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When Michel traveled from San Fernando to Sacramento to share her story with the California State Assembly Committee on Health on April 25, she was joined by others in support of food as medicine. She spoke alongside Gina Moreno-John, a University of California, San Francisco, professor and primary care physician. Eight people lined up to speak on behalf of coalitions and community organizations, voicing support for the proposed bill. There was no public opposition. 

“Think about how much money you spend on groceries per week and think about how much it costs to hospitalize a patient for a week and you get the idea about cost savings,” said Moreno-John, who had been invited by bill sponsor Assemblymember Bonta.  

“My job is to protect the wellbeing of my patients, but I need tools to do that,” Moreno-John concluded before asking lawmakers for their assistance.  

With bipartisan support, the committee unanimously approved and moved AB 1644 to the Appropriations Committee, which referred the bill for an analysis by committee staff. Staff cautioned against funding food as medicine, however, stating its cost was “unknown,” though “likely in the tens of millions of dollars or more.” In the shadow of an estimated $31.5 billion deficit for the 2023-2024 fiscal year, the bill was doomed by May. Advocates anticipated the bill’s demise this year. But there’s still time, they stress. 

California’s five-year food medicine pilot program is set to run until 2027. Advocates say that gives the Legislature enough time to commit to funding food medicine for all Medi-Cal patients. 

“California would be the first state in the country to do this, and it would be groundbreaking,” Ettman said. “This is health care; this is a win for health care savings; a win for health benefits; a win for health outcomes; and a win for treatment options. This is a win for the long term.” 

Tens of millions of dollars is nothing to dismiss. But that math doesn’t tell the whole story. California should be investing in the long-term health and well-being of all its residents, including through the simple addition of wholesome food to alleviate chronic disease and illness. It’s not apples and oranges.