In Virginia, one pediatrician tweaked electronic health record billing codes so Medicaid and private insurers are paying for patients' trips to food banks.
In California, Colorado, Massachusetts and Vermont, variant comprehensive models of getting payers involved in setting standards for dealing with food insecurity are underway or already up and running.
But the mounting push to expand and hone how the medical community treats food insecurity is clashing with the fight over food stamp restrictions currently raging on Capitol Hill. The farm bill that passed Wednesday out of the key House committee along a party-line vote would put a controversial 20-hour work requirement on adults who buy food through the Supplemental Nutrition Assistance Program.
The SNAP fight touches on healthcare policy as stakeholders from hospitals to insurers ramp up talks about confronting social determinants of health to cut costs and improve health of the general population. One recent study puts the annual direct health costs of food insecurity for the U.S. at almost $30 billion, with direct and indirect healthcare costs totaling about $160 billion. The same study estimates that more than 15% of Americans face food insecurity.
"SNAP is the biggest food assistance program that we have," said Dr. John Cook, a leading author of that study who works as principal investigator at Children's HealthWatch at Boston Medical Center.
Cook cited empirical literature that shows the program's effectiveness "both in terms of reducing food insecurity but also the health of recipients." He opposes the work requirements, as he doesn't want to see the program structurally changed in "any way that makes it more difficult for eligible people to receive" assistance to buy food.
The work requirement provision however has acquired political heft as Republicans are pushing it under the mantle of retiring House Speaker Paul Ryan's promised entitlement reform that did not materialize this Congress.
After Ryan announced he would leave the speakership and the House in January, conservatives including House Freedom Caucus Chair Mark Meadows (R-N.C.) told reporters that SNAP work requirements were the main focus of any efforts on entitlement reform in the months leading into the midterms. The work requirement was one issue that split House Democrats from the previously bipartisan talks on the farm bill, and also brought advocates working on the food scarcity issue to Capitol Hill to lobby last week, ahead of the committee's vote.
Children's HealthWatch was among these advocates. Since February the group has been unrolling work on EHRs to push for screening people dealing with food insecurity. Their work in EHRs involves a tweak to flag the sole billing code that touches on the issue of food insecurity. The group has developed a tool called the Hunger Vital Sign based on the U.S. Department of Agriculture Food Security module to help doctors screen their patients.
The goal isn't necessarily reimbursement, said Richard Sheward, deputy director of innovative partnerships at Children's HealthWatch, but rather making the screening part of the standard of care.
Since February, Vermont's two mainstay payers—Medicaid and Blue Cross and Blue Shield—have been using the code tweak. Children's HealthWatch is working on California, Colorado and Massachusetts and is speaking with other states as well.
"There is no barrier to this; there's not even a ton of convincing," Sheward said. "It's a matter of educating people, and letting folks know that it's an option, that it is an opportunity at their disposal."
Once it's a normal part of a physician or hospital's work with patients, Sheward said, the EHR incorporation can push patient follow-up and aid research on food insecurity's relation to health outcomes.
Cook and other advocates want lawmakers to see the possibilities for tightening the links between the healthcare industry and federal food programs like SNAP, but policy analysts critical of the measure passed by the House committee say it would slash food assistance available to poor families.
According to Robert Greenstein of the liberal think tank the Center on Budget and Policy Priorities, the bill would eliminate or reduce benefits for about 2 million people or 1 million households. Moreover, Greenstein projects, states would need to find work or training programs for about 3 million people every month, with about $300 per work-program slot available per year for them to do so.
Whether the House proposal will move through the Senate isn't clear. House aides close to talks on both sides of the aisle are speculating that with midterms approaching and the legislative calendar days dwindling, the upper chamber may kick the can down the road and pass a temporary reauthorization of farm bill funding, but the key senators are more coy.
Sen. Pat Roberts (R-Kan.), who chairs the Senate agriculture committee, said in a statement that his chamber's proposed legislation will be "an evolutionary—not revolutionary—farm bill" and that the lawmakers are taking "a hard look at every program and title to see where can find efficiencies and make improvements."
"As we learned at our hearing on SNAP in September, we need to improve the state quality control process to ensure that we have an accurate error rate for the program," Roberts said.
The Senate committee's ranking Democrat, Debbie Stabenow of Michigan, blasted the House committee for choosing "a partisan path that makes it impossible to pass a five-year farm bill."
"I remain committed to working with Chairman Roberts to write a bipartisan bill in the Senate focused on our farmers, families and rural communities in Michigan and across the country," he said.
