- The substantial overlap in eligibility for Medicaid and food support programs, such as the Supplemental Nutrition Assistance Program (SNAP), provides opportunities for states to coordinate their policies and processes to improve access to affordable, nutritious food.
- State agencies, including Medicaid and social service agencies, increasingly recognize the importance of integrating individual and community voices into policymaking, especially people from communities of color who experience disparities in food security.
- Opportunities to increase food access include: (1) develop a sustainable community engagement infrastructure that enable states to build meaningful relationships with and incorporate individuals with lived expertise in policy and program design; (2) center equity, humanity, and dignity in policymaking and in service provision to better serve people enrolled in Medicaid and nutrition programs; (3) address persistent eligibility and enrollment challenges through cross-agency partnerships; and (4) use state levers and authorities to advance coordination and innovations.
- Read the executive summary below, or download the full report.
Health is about more than access to health care. To improve the health of individuals it serves, state Medicaid agencies are increasingly focusing on prevention, health-related social needs (HRSN), and otherwise moving upstream.1 This broadened perspective often includes strategies to enhance access to safe, nutritious, and affordable food, particularly in the wake of the COVID-19 pandemic and in the growing evidence that participation in programs like SNAP is associated with meaningfully lower health care use and cost.2,3,4
Medicaid alone cannot dismantle the structural and political factors that contribute to food insecurity and the barriers to accessing nutritious food. By understanding the landscape of food insecurity and engaging the perspectives of people currently and formerly enrolled in food support programs, cross-agency partners can work together to dismantle barriers and advance more effective, coordinated approaches that improve health outcomes, particularly among Black and Latino individuals and families facing disproportionately high rates of food insecurity.5,6
This report, part of the Exploring Cross-Agency Partnerships to Address Food Insecurity initiative led by the Center for Health Care Strategies (CHCS) with support from the Robert Wood Johnson Foundation, offers four recommendations for policymakers to integrate individuals with lived expertise as partners in program and policy design, implementation, and evaluation to more effectively address food insecurity. These recommendations — drawn from conversations with individuals with lived expertise, interviews with state policymakers representing Medicaid and SNAP, and an environmental scan — are summarized in the following pages.
1. Reimagine Sustainable Community Engagement Strategies
Following are recommendations to incorporate insights from individuals with lived expertise who are most impacted by historic inequities into states’ policy and program design, implementation, and evaluation efforts. While these recommendations emerged in discussions specific to addressing food insecurity, many are broadly relevant to Medicaid policymaking in general.
- Reimagine states’ community engagement efforts to shift power and allow for shared decision-making. Partnering with individuals with lived expertise at every step of system design activities ensures that co-created policies not only meet the needs of people they are intended to serve, but also interrupt practices that uphold systemic racism and perpetuate existing disparities in hunger and health.
- Support relationship- and trust-building with community partners to drive engagement and cross-sector collaboration. Investing in relationship- and trust-building will help create a strong community engagement foundation that can successfully inform policy and program design to better address community needs. Co-design, which requires trust and transparency, is essential for effective and equitable policymaking as policies designed without meaningful input from community members most impacted can have unintended consequences that further traumatize them.
- Compensate for time and expertise. States may consider addressing barriers to equitably compensating community members across agencies, including amending statutes that prohibit states from providing stipends or other payment arrangements for community members’ time and penalize program participants with the loss of benefits for receiving these stipends. This will require a shift in how states and organizations perceive work with individuals with lived expertise, and coordinated efforts to overcome regulatory hurdles, explore additional funding streams, and embed engagement efforts into budgets.
- Consider hiring Medicaid and social services agency staff with lived expertise to better inform program planning, implementation, and evaluation. Including individuals with lived expertise in all levels of planning and implementation can enrich the systems that states are working to build to address social determinants of health and HRSN, including food insecurity.
2. Center Equity, Humanity, and Dignity in Policymaking and Implementation
Following are recommendations for cross-agency partnerships to address food insecurity from a person-centered, trauma-informed, and equity-centeredlens to better serve individuals enrolled in Medicaid and food programs.
- Convene state policymakers/program administrators, enrollment staff, and community members to discuss the current system and learn from individuals with lived expertise.
- Incentivize increasing access to Medicaid and food assistance programs rather than preventing fraud, since the latter often contributes to trauma and stigma, and disproportionately harms Black and Latino individuals and families.
- Conduct trauma-informed policy and service delivery training programs for Medicaid and SNAP program administrators and frontline workers so they can better assess and assist individual needs of applicants and enrollees.
- Develop and implement education programs for state and local Medicaid and SNAP staff (and other public assistance programs, like WIC) about the history of inequitable policies and systems, including “race neutral” policies that perpetuate structural racism, and how to operationalize these learnings.7
- Embed equity impact assessments into policymaking processes prior to approval for implementation. Further, incorporate a mandatory requirement to engage with community members before policy or process changes can be implemented. Alternatively, consider hiring individuals with lived expertise as staff or consultants to proactively share insights to inform new policies and to identify policies that may look good on paper but have unintended negative consequences for enrollees.
3. Address Persistent Eligibility and Enrollment Challenges Through Partnerships
Following are recommendations for improving the enrollment and eligibility process:
- Invest in data and technology systems. Invest in information technology infrastructure that bolsters data-sharing across programs and potentially facilitates applications across programs. States can also establish data-sharing agreements between partnering agencies to improve access to programs. Further, states can engage community members with lived expertise in these processes to help identify potential unintended consequences.
- Engage in redesign at the federal level. Some federal programs have not been revamped in over a decade, which exacerbates the issue of programs being overseen by different agencies with different requirements impacting alignment. Opportunities exist to reassess eligibility requirements across federal programs, develop consistent standards across states, and consider realities of employment — given that an individual’s income can vary drastically from month to month, particularly for individuals that are self-employed or gig workers — in determining eligibility.
- Involve individuals with lived expertise. States can collaborate with the community and individuals with lived expertise to ensure that outreach and enrollment strategies meet community needs. The state can use a human-centered design process to reimagine the eligibility and enrollment process. In this process, individuals with lived expertise are engaged to help state officials better understand what individuals in need are facing.
- Explore innovative multi-sector partnerships. At the state level, identify opportunities to involve sister agencies or departments (i.e., those that administer SNAP, WIC, Older Americans Act Nutrition programs) in Medicaid policy development relating to food insecurity. States can seek opportunities to coordinate beyond their usual partners to enhance eligibility and enrollment.
4. Use Medicaid Levers to Screen for Food Insecurity and Provide Needed Services
Following are recommendations for using Medicaid policy levers, including managed care contracts and 1115 demonstrations with additional food-related services, to screen for food insecurity and provide needed services.
- Strengthen community resources. State Medicaid agencies and health care organizations are increasingly working to expand screening for social risk factors, but often worry that individuals will not be able to access services that address identified needs. While scarce resources can complicate navigation and referral, screening results can nonetheless help inform clinical decision-making and help Medicaid members access available services, e.g., SNAP. Aggregated data from screening and referral processes can help state Medicaid agencies and others to visualize the depth of food insecurity needs, map gaps in community resources, and attempt to close those gaps.
- Identify accountability measures that resonate with communities and individuals with lived expertise. Community-defined measures can help keep governments accountable to the people they serve. Regional organizations, like accountable health communities and health equity collaboratives, can help facilitate discussions with community members and ensure that policy development is collaborative, transparent, and responsive to community needs and priorities.
- Expand access to healthful, culturally preferred meals and foods. Medicaid can help individuals access nutrition supports that are otherwise unavailable through SNAP. For example, individuals experiencing homelessness, individuals who need assistance with activities of daily living, or people recovering from an inpatient stay may have difficulty preparing meals using groceries purchased by SNAP.8 Medicaid enrollees should have the dignity to choose among meals and food that they enjoy, and to receive foods that contain the calories needed to alleviate hunger.
No one should go to bed or wake up hungry. To improve the health of people eligible for Medicaid and food assistance programs, states have an important opportunity to coordinate with sister agencies and programs to improve access and service delivery and better meet people’s health care and health-related social needs. In doing so, states — working across silos — can reimagine their policies and programs by involving individuals with lived expertise in communities most affected by structural racism, inequity, and trauma. The insights and state examples highlighted in the accompanying report offer guidance for pursuing cross-agency and community partnerships and actions. By considering the concrete, actionable recommendations herein, states can explore and implement these ideas in a broad, collective approach to address food insecurity in a person-centered, equitable manner.
- D.R. Williams, M.V. Costa, A.O. Odunlami, and S.A. Mohammed. “Moving Upstream: How Interventions that Address the Social Determinants of Health can Improve Health and Reduce Disparities. Journal of Public Health Management and Practice, no. 14 (2008): S8–S17. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3431152/.
- C. Hall, S. Artiga, R. Garfield, R. Food Insecurity and Health: Addressing Food Needs for Medicaid Enrollees as Part of COVID-19 Response Efforts. Kaiser Family Foundation, August 2020. Available at: https://www.kff.org/report-section/food-insecurity-and-health-addressing-food-needs-for-medicaid-enrollees-as-part-of-covid-19-response-efforts-issue-brief/.
- S.A. Berkowitz, D. Palakshappa, J. Rigdon, H.K. Seligman, and S. Basu. “Supplemental Nutrition Assistance Program Participation and Health Care Use in Older Adults.” Annals of Internal Medicine, October 19, 2021. Available at: https://www.acpjournals.org/doi/10.7326/M21-1588.
- D.X. Morales, S.A. Morales, T.F. Beltran. “Racial/Ethnic Disparities in Household Food Insecurity During the COVID-19 Pandemic: A Nationally Representative Study.” Journal of Racial and Ethnic Health Disparities, 8, (2021):1300–1314. Available at: https://doi.org/10.1007/s40615-020-00892-7.
- J. Stephenson. “Coronavirus Disease 2019 has Worsened Food Insecurity Among Families with Low Incomes, but Medicaid Is a “Potential Vehicle” for Relief.” JAMA Health Forum, 1, no. 9. (2020); e201151. Available at: https://jamanetwork.com/journals/jama-health-forum/fullarticle/2770754.
- Morales, et al., op. cit.
- M. Allen. Racism in Public Benefit Programs: Where Do We Go from Here? Center for Law and Social Policy, July 23, 2020. Available at: https://www.clasp.org/blog/racism-public-benefit-programs-where-do-we-go-here.
- Centers for Medicare & Medicaid Services. SHO# 21-001. RE: Opportunities in Medicaid and CHIP to Address Social Determinants of Health (SDOH). Available at: https://www.medicaid.gov/federal-policy-guidance/downloads/sho21001.pdf.