ALONG WITH spacious skies and amber waves of grain, the American landscape features food deserts — places where fresh produce is scant, dotted with high-calorie oases where the poor can most readily afford foods flush with sugar, fat, and salt. One in every seven US households experiences not having enough food to go around the table. These families, who live among us in cities and rural America, are deemed “food insecure,” a term that encompasses the two-headed beast of hunger and chronic malnutrition among the overweight and obese.
Food scarcity is also a force multiplier for disease: Research shows that adults facing severe food insecurity are more than twice as likely to have diabetes than those with regular access to healthy food. About one in three chronically ill patients in the United States cannot afford to buy food, medications, or both. The Center for American Progress estimates that in 2010, lack of access to healthy food was responsible for $130.5 billion in health care costs. The costs of this food insecurity will be increasingly borne by taxpayers and businesses as health care coverage expands under the Affordable Care Act.
The prescription for government and philanthropies has long been clear: Invest in healthy, accessible, and affordable food for the poor. But recent policy changes and pilot programs also point to a role for hospitals in breaking this vicious cycle for the 17 million families across the United States who experience food insecurity.
Nonprofit hospitals, which make up about 60 percent of American hospitals, have historically justified their tax exemptions from federal and state government by offering charitable services in communities where they operate. Community health clinics and free and discounted care for poor patients have been among their tactics. But most nonprofit hospitals have not been required to report in detail exactly what they are doing to help people in need. Measures to prevent disease have not been required. Many hospitals have aggressively collected overdue payments from low-income patients, a practice that is discordant with being deemed charities.
The Internal Revenue Service, not typically a target of praise, issued rules on New Year’s Eve that for the first time require nonprofit hospitals to curb such debt collection, and to evaluate every three years their communities’ health needs and report how they are acting to solve them — both by subsidizing treatment for patients in need but also by striking at the root causes of illness. The new rules encourage but do not require hospitals to help “ensure adequate nutrition,” prevent disease, and address socioeconomic and environmental factors affecting community health. It’s an open door inviting mission-driven hospitals to go beyond treating illness to tackle the underlying drivers of chronic disease, including inadequate access to healthy food. This is a mission worthy of their nonprofit status.
New England has been a testing ground for possible actions hospitals can take. In Massachusetts, the Attorney General’s office asks hospitals to voluntarily report how they are investing in community benefits. The office estimates that in 2013, the 52 nonprofit hospitals and health care centers in this state spent $591 million on community benefits, of which $72 million was spent directly on free and discounted health care for patients and the rest went to other community programs. (The passage of state health care reform in 2006 and universal coverage may have something to do with these hospitals’ choice to devote resources to efforts beyond offering discounted care.)
Holy Family Hospital in Methuen runs a prescription program for fruits and vegetables that gives some patients $1 per day per family member to subsidize buying fresh food at farmers markets. Jordan Hospital in Plymouth pays for a community dietician, Marcia Richards, who helped redesign public school lunches and labels healthy foods in local markets. Mass. General screens patients for signs of food insecurity and offers a food pantry. A forthcoming report from the nonprofit Health Care without Harm documents 80 food access programs that Massachusetts hospitals are investing in, and calls for further measures, such as matching food stamp dollars for fresh produce.
Two Connecticut organizations, Fresh Advantage and Wholesome Wave, broker partnerships with hospitals to improve food access and make hospital cafeterias healthier; they pushed for the recent IRS rules.
Despite such programs, poverty, hunger, malnutrition and related diseases continue to scourge communities in New England and across the nation. It will take far more investment and far more leadership. As the Affordable Care Act is adjusted and the epidemics of diabetes, heart disease, and obesity spread, a reckoning with the skyrocketing costs of health care looms large. Government budget cuts continue to hack away at food subsidies for the poor, exacerbating these costs over the long term. This is a defining moment for hospitals to lead and live up to their charity status, which means fulfilling a role the government alone will not: helping keep patients out of the hospital and in their homes, with fresh food at the table.