the health disparities podcast

Food as medicine and the role of Medicaid in addressing social determinants of health

Food insecurity is a systemic public health issue that needs to be addressed because reliable access to healthy food is critical to positive health outcomes.

Health care partnerships are forming to improve access to healthy foods in some states, including Massachusetts, which is at the forefront of addressing food insecurity with programs that allow Medicaid funding to be used to address social determinants of health.

“I would push back on the idea that things like food and housing are not actually medical,” says Jennifer Obadia, senior director of health care partnerships at Project Bread, a nonprofit focused on creating a sustainable, system-wide safety net in Massachusetts for anyone facing hunger.

“Now, I understand they’re not pharmaceutical,” she adds. “But we know that 80% of a person’s health is determined by social and environmental factors.”

In this week’s episode, Jennifer Obadia speaks with Movement Is Life’s Sonia Cervantes about food insecurity, Project Bread’s mission, lessons learned over the years and shares a call to action for listeners.

Project Bread’s FoodSource Hotline (1-800-645-8333) is the food assistance line for all of Massachusetts, whether you need help paying for food and don’t know where to start or you’re simply curious about ways to boost your food budget or save on groceries.

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The transcript from today’s episode has been lightly edited for clarity.

Jennifer Obadia: Sometimes it’s hard to believe in a country that has so many resources that there are millions of people who go to bed hungry every night. So you know, here in Massachusetts, estimates range, but over the course of the year, it’s estimated that about a third of all residents will experience food insecurity. For some that might be the stress of wondering where their next meal is going to come from, and will the resources that they have take them through the end of the month? Will they be able to put food on the table for themselves and for their children in a more acute form, that actually is individuals who are skipping meals or eating less than they know they need to for their health because of a lack of resources.

Sonia Cervantes: You are listening to the Health Disparities podcast from Movement Is Life. I am Sonia Cervantes, a member of the Movement Is Life steering committee and founder of Sonia’s Healthy Corner, providing nutrition education and healthy cooking classes for all ages. Food insecurity is a systemic public health issue that needs to be addressed because reliable access to healthy food, it’s so critical to positive health outcomes, wouldn’t you agree? Well, in some states, healthcare partnerships are forming to improve access to healthy foods. Massachusetts is one of those states at the forefront of addressing food insecurity with programs that will allow Medicaid funding to be used to address hunger as a social determinant of health. To learn more, I am joined by Jennifer Obadiah. She is the Senior Director of healthcare partnerships at Project Bread Jennifer, welcome to the Health Disparities podcast. Thank you so much for being here.

Obadia: Thanks for having me. Sonia. Pleasure to be here.

Cervantes: So can you start by telling us about your role at the Project Bread, and what led you to this work at the intersection of healthcare and food access?

Obadia: Absolutely. So I am really fortunate to work at Project Bread, which is a statewide food security organization, which really has the ultimate goal of ending hunger statewide for all members of Massachusetts, and we really take a systemic approach, really trying to address policy and systems to address the root causes of hunger, because we fundamentally believe that hunger is not an individual failing, but it is a result of the current systems that we have in place in the state and in this country. So we really aim to meet people where they are. So a lot of our work is in schools and in healthcare sectors that most people interact with at some point in their, you know, everyday life.

So we started working with accountable care organizations, which is what we call the insurers here in Massachusetts, that work with the Medicaid population back in 2020 as they piloted for the first time, what was called flexible services, which was really the opportunity to utilize Medicaid dollars to address both food and housing here in Massachusetts. And so over the last five years, that work has grown. We have evolved from a pilot into a semi permanent program where we really have the opportunity to work hand in hand with the health care sector, with our partners serving lower income residents of our commonwealth.

Cervantes: That’s amazing. So for those of you that might be unfamiliar, can you briefly explain what food insecurity looks like in Massachusetts and literally across the United States?

Obadia: Yeah, absolutely. So, you know, sometimes it’s hard to believe in a country that has so many resources that there are millions of people who go to bed hungry every night. So you know, here in Massachusetts, estimates range, but over the course of the year, it’s estimated that about a third of all residents will experience food insecurity. For some that might be the stress of wondering where their next meal is going to come from, and will the resources that they have take them through the end of the month? Will they be able to put food on the table for themselves and for their children in a more acute form, that actually is individuals who are skipping meals or eating less than they know they need to for their health because of a lack of resources and so, you know, we see across across the state that, of course, this isn’t a static issue, right? Someone is in food insecure all day, every day, but they might experience cyclical moments throughout the course of a month, depending on when they receive their paycheck, what other assistant benefits they’re able to receive, and we know that that lack of consistent and reliable access to nutritious food is of course, going to have a negative impact on their overall health and wellbeing.

Cervantes: Yeah, it’s unfortunate, right? Because we see that increasing. So Project Bread healthcare partnerships, the program has been called a revolutionary approach in the food is medicine movement, which I think it’s amazing, and I’m biased, because I love food is medicine as well. What sets this program apart from other food assistance or health interventions?

Obadia: Yeah, so I of course, am biased as well, because I’m very proud of the program that we’ve built here, and just have to give, you know, a big shout out to all of my colleagues here at Project Bread, particularly our direct service providers, who are the ones who are speaking with patients day in and day out to address their immediate needs. But I think there’s a couple of things that make our program unique. One is that it’s not just food. So in a nutshell, a person will have an experience with their primary care provider or at a community health center or an emergency room, and they’ll be identified by the medical system as experiencing food insecurity and having a chronic health condition. Those two things together are what make them eligible the medical need and the social need. They get referred to Project Bread, and we’re able to do several things. We are able to address their immediate food needs, and we do this in the form of a food benefit card.

So it’s a card that they receive. It gets reloaded each month with $100 that they’re able to use at any number of the local supermarkets across the state. And it is slightly restricted, so they can’t buy just anything, but they can buy most all foods. And so in addition to providing them with that card, we also invest heavily in education, so we believe that people know what’s best for them, right? You know what’s appropriate for you to eat. You know what is acceptable for you and your family based on your culture, your background, your medical conditions. So we don’t necessarily provide prescribed food, but what we do is we provide the capacity for them to purchase food and the education for them to better understand how food plays a role with their medical condition. So we do that in two ways. One is that we have a team of dietitians here so people can have one on one counseling with a registered dietitian.

And additionally, we provide general cooking classes, so we have a different cooking class each week where people can learn about eating well with diabetes, or healthy foods for kids or just cooking on a budget, kind of classes. So we provide that education. And in addition to that, one of the really wonderful things that we’re able to do here is we’re able to purchase kitchen supplies for people. So you know, I remember one of our very first clients, actually the first member that I ever worked with. Back in 2020 they needed food, but they were unable to receive the previous food that had been offered to them because they didn’t have a refrigerator or a stove. So they had no way to store their food or to cook it. And so what this program was able to do was to actually buy a refrigerator for this individual, and that opened up a like a whole world of possibilities, then of what they could be eating, they no longer had to shop only for the non perishable items that they could access, the fruits, the vegetables, the lean meats, the the, you know, the dairy, etc.

So I think that’s one of the really wonderful things, is we really try to understand what are the unique barriers that an individual is facing, and we can come at helping to address those barriers from a variety of different angles, not just the food but the support that we all need to be able to make the most of our of our meals, in terms of, you know, benefiting our health and our way to the active members in our society. If I could go on just a little bit longer, I do want to add, in addition to the parameters of what the actual program can do, it is the team that makes this so incredible. It is the team here at Project Bread, the fact that many folks come from the same countries of many of the members that we’re serving, they’re multilingual, so we have staff that speaks English and Spanish and Portuguese and Haitian Creole and Arabic and Vietnamese. So we’re really able to connect with people in their own language, but also understand the cultural relevance that food plays in their life, and that means that our dietitians are able to make recommendations that will be acceptable, that can really lead to behavior change. And then, in addition to our team, the health care providers, the community, health workers that we work with are so incredible, and they go above and beyond. And beyond. If the referral we get has a phone number that isn’t working, we reach out, and they say, Here’s three other ways to reach this person. So very few people fall through the cracks. It’s really, we’re so lucky.

Cervantes: Sounds like an amazing team. That’s great. And that leads me to my other question. You mentioned healthcare providers, can you walk us through the program and how it integrates precisely with healthcare providers? What does collaboration look like between Project Bread and doctors or clinics? So when you say healthcare providers more specifically with the doctors, do you typically? I mean, do they refer you the people directly?

Obadia: Yeah, absolutely. So you know, folks can be identified as being eligible for the program in a lot of different ways, but mostly the way that it happens is someone is already interacting with their health care provider. A lot of that time. It’s a community health center, so they have come in for either, you know, a well visit, or because they’re not feeling well, or whatever the reason might be. And as part of the requirements for the accountable care organizations here in Massachusetts, everyone needs to be screened for a variety of different social determinants on an annual basis. So when someone is having that point of contact with the healthcare sector, whether it’s, you know, their primary care provider or the emergency department, they will be asked these questions. And so that’s really how that social need is uncovered, and then we get the referral. And over the years, we’ve been able to develop a pretty wonderful technological solution that really allows for bi directional communication between our team and the medical team. Typically, when I’m referring to the medical team, it is the Patient Navigator, the community health worker, you know, sometimes nurses, less often is it the actual physician itself? But it’s because folks who have been identified of having need, have been referred into programs where they get a case manager right to help with all of those other needs so that they can focus on improving their health.

Cervantes: That’s right. A lot of collaboration, for sure. So now the idea of using Medicaid dollars for non medical issues, or, you know, things like food and housing is perhaps surprising to some. How did that come about, and why is that shift so important nowadays?

Obadia: Yeah, so I think that really, I would push back on the idea that things like food and housing are not actually medical. Now, I understand they’re not pharmaceutical right? But we know that 80% of a person’s health is determined by social and environmental factors. That’s really quite a small portion that is addressed through that direct interaction with the health care system itself. So we know that if we want people to live full, healthy lives, those social needs, the food, the housing, they have to be addressed, and without that really, the medical intervention itself has a much harder time taking root. So for example, we did some research where one of my colleagues, our Director of Research here, Laura Siller did, her team did some interviews with community health workers, and what they reported to us was that by addressing the food need, by taking that really fundamental, critical need off the table for their members, for the patients that they were working with, it opened the opportunity for them to focus on things like the heart disease or the diabetes, because until those basic needs are met, that’s where people’s minds are. If you are a parent and you cannot put food on the table for your child, that is the number one thing that is driving your every decision, and your individual health will suffer for it.

Cervantes: Right? Absolutely, absolutely. Thank you for that. Over the years, Project Bread has supported over 17,000 patients. So that’s a lot of complex medical issues. Can you share a patient’s story that illustrates how this program can transfer someone, someone’s health in life?

Obadia: Sure, absolutely, I think I can do that in two ways. For folks who like the numbers, one of our partners did some analysis, and they found that people who engaged in our program for at least six months that they saw their a one that an average drop in the a1c which is the hemoglobin a1c for individuals with diabetes, dropped by one and a half percent. So that means going from 11 to 9.5 is what they saw with those really high risk diabetes individuals. Do we want people’s a1c to continue to drop lower, absolutely. But is that huge project progress? Definitely. So we see in some of the numbers the stories starting to unfold, but then we also hear it through the individual conversations, right?

So I actually have beside me a list of stories from the team, and one that really stuck out to me was a child who was referred to the program, and they had cerebral palsy, and they had a very difficult time eating because they could only swallow soft or liquid foods. And for a household that was very cash strapped, did not have a lot of equipment in their kitchen to prepare food, it was very difficult for the child to be able to eat. So not only did the program provide financial resources so that they were able to purchase a variety of different foods for the kid, we were also able to purchase a blender, and that one simple piece of equipment meant that this child now could engage in meals in a way that they couldn’t before, and that opened up so many possibilities for that. So that’s just one small example of the ways that this program can really have an impact.

Cervantes: Made a world of difference, huh? That’s amazing. Nearly 40% of recent participants in Project Bread are children, which is really sad. Is that correct?

Obadia: That is correct. We do see a large number of referrals for individuals under the age of 18. I think it’s both sad, but it also has the most possibility for change, because we know that especially early childhood is such a critical time in development. So if we can invest in the health and well being of kids while they’re young, we’re setting them up for such a brighter, healthier, more active life as they grow older. So I try to look at that percent as an opportunity. But yes, we see tons of children here, across the state, and really across the country, who you know, are living in poverty. They have limited access to food, and that relates to a lot of corresponding health conditions. And increasingly, as you know, we hear all the time a lot of really challenging behavioral health conditions, so things like anxiety and depression increasingly impacting younger and younger children, and so that’s one of the main reasons why we do start to see more children enrolling in programs like this.

Cervantes: That’s great. So early intervention, right?

Obadia: Absolutely, absolutely, absolutely. And I’ll just add to that, you know, this one program, obviously is not going to solve hunger. It’s not going to, you know, magically transform everyone’s lives, but because of the coordination, if we can help to build a bridge and make sure that you know that child is also connected to SNAP benefits, and that their family also knows where the summer meal sites are to get food when school is out of session, we can help them weave together the variety of resources, and we really start to have an impact on that individual life and the life of the whole family.

Cervantes: Absolutely, you start with the kid and it just transfers to the rest of the family. Absolutely, okay. So starting in January 2025, this program becomes a covered benefit for Mass. health patients. What did it take to get there, and what does this milestone mean for the future of healthcare delivery in Massachusetts?

Obadia: I am so grateful to the state to Mass. health for really making this milestone possible. I do think it is really a huge step forward. As far as I’m aware, we’re the first state to really integrate it as a covered benefit, and what that means is, if an individual meets the eligibility criteria, the program is offered to them. So prior to 2025 it worked more like a grant program. So each accountable care organization may be focused on a different population, maybe some focused on high risk youth, others high risk pregnancy, but it wasn’t available across the board. Now this program is available to every member of an accountable care organization, and every Accountable Care Organization is required to offer at least one housing and one nutrition service. So we’re really, really changing what the baseline looks like for people here in Massachusetts. So it’s really incredibly exciting. It took a lot of hard work, a lot of trial and error and a lot of partnership.

Cervantes: Definitely sounds like it, so let’s talk about what’s happening. So i s funding for Project Bread and other Medicaid funded initiatives like yours, is it at risk given the recent federal action to cut Medicaid spending going forward?

Obadia: So it’s a very timely question, and it’s a very complicated question, speaking just for Massachusetts, because it’s a little bit different in every state because of the way this work is authorized on sort of a state by state basis. Here in Massachusetts, our state supports this work. The mass health or Medicaid agency supports this work. The governor supports this work. So we really have a broad base of, you know, goodwill towards this progress, and the state is going to have a very tight budget. So it’s not that there are required cuts, or that this will no longer be allowed, or anything like that. It’s just, how does the state manage with significantly fewer resources coming in from the federal government? And so that is going to cause, you know, a host of challenges to all sorts of programs within Medicaid or not, because you’re just the pie just shrunk, right? And the need didn’t go anywhere. So, and then the Medicaid specific component, I think, where the state’s hand is really tied is around eligibility. So we might see the pool of people that are eligible for Medicaid shrink. And in fact, the governor’s office did put out a press release about a month ago at this point that it suspects that about 250,000 people will no longer be eligible for Medicaid in the state. And that’s just, you know this, there’s nothing that the state can do about that that’s just based on the big bill.

Cervantes: Yeah, okay, well, yeah. But you know, you’re, you’re doing an amazing job, and you’re right, you know, when things shrink, you always figure it out, right? So that’s, that’s amazing what you guys do. So with that being said, and you know, you talked about Massachusetts, of course, but what listens or insights from the last four years could help other states replicate?

Obadia: Yeah, I mean, I think there’s a handful of things. One is, you know, Massachusetts was lucky. We started big. You know, there was a lot of sport from across all sectors, and so we just rolled it out full steam. But there’s no reason that you can start small too. So, you know, if your state can get approval through one of these waivers, which essentially, it’s called an 1115 waiver, it’s a mechanism where states get to test out different types of innovations within Medicaid with the approval of the federal government. So advocate for one of those waivers so that you have the regulatory authority to try things. It can be a small pilot. Just get the ball rolling. If that doesn’t work. There are other mechanisms. California has used something called in lieu of services, which just makes it possible that providers can offer these types of services. It doesn’t require it, so there’s a different level of engagement, but it is a possibility. And then I would say, don’t be afraid to reach out to people that you might think are your competitors, other, other, you know, service providers, because you’ll be stronger together.

The need is so great. I don’t think we need to worry about, you know, competing. And I think, you know, oftentimes, as part of the nonprofit community, health insurance seems big and scary, and there are so many people working within those systems that just want to take care of their members. They just want to see people healthy and thrive, and don’t be afraid to reach out to them. Don’t be afraid to try something. Don’t be afraid to get rejected, because it’ll happen more times before something actually gets off the ground. So I think we just, we need to be brave. We need to put on our big kid pants and just, you know, trudge forward. And I think each state, little by little, making progress is what’s going to lead us to a national movement where no longer is this on each individual state, but where these are approved services across the board and can really be just part of how we conceptualize healthcare.

Cervantes: Thank you for those encouraging words. Yeah, so with food insecurity still affecting one in six households in Massachusetts, yes. What’s your long term vision for solving hunger at a scale, how close or far are we from that goal?

Obadia: I’m excited to share that there is a coalition that recently launched called make hunger history. Right? And it is a cross sector group of folks working here in Massachusetts to answer that very question. Sonia, so I don’t know that I have an answer yet, but I think, you know, part of the solution is, you know, our systems are not necessarily broken. They’re kind of doing what they were designed to do, I just don’t think they were designed to do the right things. So it’s really getting under the hood and reconfiguring some of the incentives for how our systems work. Because it’s not a lack of food, it’s not even a lack of money, it’s really sort of the political systems that are leading to this challenge.

Cervantes: Okay, okay, well, thank you for that, and obviously we’ve been talking about your involvement and all this collaboration and partnerships. But for those of us that are listening to the podcast, how can listeners, whether they’re health professionals, policy makers, or just simple everyday people get involved to support this kind of systemic change?

Obadia: Yes, absolutely. First thing I would say is get to know your representative, your state representative, get to know your city councilors, and let them know that this is something that matters to you. Keep this issue on the top of their agenda, because there will always be competing issues. And they say, for every one person that they hear from, they assume 10 more people feel the same way. So your voice carries a ton of weight. So don’t be shy. Get out there. Talk to your representatives. Their job is to represent you and your needs, right? That’s the thing. Number one. Number two, if you can afford it, find an organization that you can support that’s doing this work on the ground, be it Project Red or any number of other organizations across Massachusetts, resources are tight, and for us to keep doing our work, even $5 a month goes a long way. Those would be my top two. The last thing that I would say is show compassion to your neighbors. People who are experiencing food security are all around us, and we don’t necessarily know, right? So whether it’s compassion in the sense of someone’s really short tempered with you at work and you don’t know why they had to skip a meal, maybe something really hard is going on in their life. Just have a little more patience. And that person that you pass on the street, let’s not assume we know what their story is. If they need something to eat, maybe you can provide that meal, not changing the system, but you sure are making someone’s life better that day.

Cervantes: Absolutely thank you for that. I think that’s so important and so much on point. We’re all so busy, and we live our lives like, you know, just go, go, go, and it’s, it’s, it’s challenging, right? Sometimes we’re just oblivious. So thank you for that reminder.

Obadia: Sure. I mean, yeah, and I do the same thing too. Sometimes I’m so tunnel visioned on get that email out, do the thing, but we need to pick our heads up and remind ourselves of that shared humanity.

Cervantes: Absolutely. Well, we’re going to have to leave it here. Thank you so much, Jennifer, for joining us on the Health Disparities podcast, and we’re so appreciative that you’re here. Obviously this is so enlightening, and for those of you that are listening to our podcast and want to learn more, we will include the links to Project Bread’s website in our notes on this show for today’s episode. That brings us to the end of another episode of the Health Disparities podcast from Movement is Life. I’m Sonia Cervantes, and until next time, be safe and be well.

Obadia: Thank you.