https://static1.squarespace.com/static/5c82ced1a56827591142c3df/t/5e31b3636f5f284942716c7e/1580315492481/CS_CHLPI+Testimony+SB+2453.pdf

January 22, 2020
Senator Joanne M. Comerford
Senate Chair, Joint Committee on Public
Health
Massachusetts State House, Room 413-C
Boston, MA 02133
Senator Nick Collins
Senate Vice Chair, Joint Committee on
Public Health
Massachusetts State House, Room 312-D
Boston, MA 02133
Representative John J. Mahoney
House Chair, Joint Committee on Public
Health
Massachusetts State House, Room 130
Boston, MA 02133
Representative Chynah Tyler
House Vice Chair, Joint Committee on
Public Health
Massachusetts State House, Room 155
Boston, MA 02133
Re: An Act Relative to Establishing and Implementing a Food and Health Pilot Program
(S. 2453)
Dear Senate Chair Comerford, Senate Vice Chair Collins, House Chair Mahoney, and House
Vice Chair Tyler,
On behalf of the Center for Health Law & Policy Innovation of Harvard Law School (CHLPI),
Community Servings, and the undersigned organizations and individuals, we are grateful for the
opportunity to express our support for Senate Bill 2453, An Act Relative to Establishing and
Implementing a Food and Health Pilot Program.
CHLPI advocates for legal, regulatory, and policy reforms to improve the health of underserved
populations with a focus on the needs of low-income people living with chronic illnesses.
Community Servings is a not-for-profit food and nutrition program with the mission to actively engage the community to provide medically tailored, nutritious, scratch-made meals to
chronically and critically ill individuals and their families.
In June 2019, CHLPI and Community Servings published the Massachusetts Food is Medicine
State Plan. The State Plan is the product of a two-year, community-driven initiative that engaged
over 400 individuals from across the state to identify health and food system reforms to improve
access to critical nutrition interventions and change the culture and practices of the health
system, so that it is equipped to respond to individual and community-level nutrition needs.
Following the release of the State Plan, CHLPI and Community Servings launched Food is
Medicine Massachusetts (FIMMA), a multi-sector coalition comprised of over 50 organizations
representing nutrition programs, patient advocacy groups, health care providers, health insurers,
2
academics, and professional associations, all committed to implementing the goals of the State
Plan.
Thanks to the innovative work of our state legislators and agencies, Massachusetts has long been
a national leader in health care policy. We have led the way in ensuring universal access to
health insurance coverage, and we continue to be at the forefront of innovative reforms such as
implementing value-based payment. However, we continue to struggle with two issues that play a fundamental role in driving health outcomes and health care costs: food insecurity and dietrelated disease.
Across Massachusetts the diet-related diseases of cancer, diabetes, chronic lower respiratory
disease, stroke, and cardiovascular disease “contribute to 56% of all mortality . . . and 53% of all
health care expenditures.”1 Underlying these troubling trends is the fundamental issue of access
to adequate nutrition. Food insecurity, or the lack of consistent access to enough food for an
active, healthy life, impacts one out of every ten households in Massachusetts,2
and results in
$1.9 billion in avoidable health care costs each year.3

For many households, improving basic access to nutritious foods through programs like SNAP
may be sufficient to improve health. However, for individuals living with or at risk for serious
health conditions affected by diet, these strategies do not go far enough. These individuals not
only need access to nutritious foods, but equitable access to Food is Medicine interventions—
foods specifically tailored to address the impacts of their health conditions.
A growing body of evidence indicates that connecting these individuals to Food is Medicine
interventions may be an effective, low-cost strategy to improve health outcomes, decrease use of
expensive health care services, and improve patient quality of life. Studies show, for example,
that medically tailored meals are associated with reductions in Emergency Department visits,
inpatient admissions, emergency transports, admissions into skilled nursing facilities, and total
health care costs,
4,5 while interventions such as medically tailored food packages can strengthen
patients’ ability to manage complex diet-related diseases such as diabetes.6
Unfortunately, despite the evidence, access to Food is Medicine interventions remains limited.
Pioneering programs exist, but structural and institutional barriers—lack of integration into
health care referral systems, gaps in research, and lack of sustainable funding—have historically
limited the ability of these programs to scale up to meet the growing need of communities across
the state.
CHLPI and Community Servings support Senate Bill 2453, as we believe it would help
overcome these barriers, further cementing Massachusetts’s role as a leader in access to care.
Specifically, we believe that, if enacted, Senate Bill 2453 will:
 Add to the body of evidence supporting Food is Medicine and provide valuable data
on the impact of Food is Medicine interventions on health care costs and outcomes;
 Enhance the ability of the Massachusetts health care system to provide appropriate
nutrition services based on patient need; and
3
 Expand access to Food is Medicine interventions in the state.
Senate Bill 2453 Will Add to the Body of Evidence Supporting Food is Medicine and
Provide Valuable Data on the Impact of Food is Medicine Interventions on Health Care
Costs and Outcomes
In developing the State Plan, we had the opportunity to take a deep dive into current research on
the relationship between food and health. This research clearly establishes food insecurity’s role
as a key driver of poor health outcomes and rising health care costs. It shows that:
 Total health care costs, including inpatient care, emergency care, surgeries, and drug
costs, increase as food insecurity severity increases;7, 8
 Food-insecure individuals often have lower quality diets, including lower intake of
produce, than their food secure counterparts, contributing to poorer health outcomes;9
and
 To mitigate limited financial resources, food insecure individuals often adopt coping
strategies that may be harmful to health such as delaying or forgoing medical care;10, 11
engaging in cost-related medication underuse;12, 13, 14 choosing between food and other
basic needs such as utilities;15, 16 opting to consume low-cost, energy-dense foods;17, 18, 19
and/or forgoing food needed for special medical diets.20
In contrast, as noted above, research has shown that connecting individuals with diet-related
disease to Food is Medicine interventions can improve health outcomes while controlling costs.
For example, a 2019 Massachusetts-based study found that receipt of medically tailored meals
was associated with 49% fewer inpatient admissions, 72% fewer admissions into skilled nursing
facilities, and a 16% reduction in total health care costs.21 Similarly, pilot studies of medically
tailored food package and nutritious food referral programs have found improvements in key
health indicators such as HbA1c for individuals living with diabetes,22, 23 fruit and vegetable
intake,24 self-efficacy, 25 and medication adherence.26
Although this initial data is compelling, notable research gaps continue to limit our
understanding of how Food is Medicine interventions can most effectively and efficiently be
implemented in the Massachusetts health care system. First, current research focuses on the
impact of single interventions (e.g., medically tailored meals or medically tailored food packages
or nutritious food referrals) on health care outcomes and costs. While these focused studies are a
useful starting point, they do not fully capture the lived experience of patients navigating the
health care system. Every day, health care providers see patients with a range of nutritional
needs. To date, though, no studies have assessed the impact of tackling that reality by offering a
range of Food is Medicine services tailored to individual patient needs. Senate Bill 2453
proposes to do exactly this. We therefore support Senate Bill 2453 because of its potential to
provide holistic models of nutrition care services as well as data on this critical point.
Additionally, we believe that with small changes, Senate Bill 2453 could go even further in
filling gaps in our current knowledge. For example, there is currently little research into the
impact of serving a patient’s entire household rather than just the individual patient. Nutrition
service providers across Massachusetts often provide services at the household level, when they
4
have the resources to do so through philanthropy or grant funding. They take this approach
because they know that in a food-insecure household, a parent or caretaker will share the food
that they receive to lessen the suffering of their dependents, children, or partner. As a result, if
the household is only receiving enough food for a single person, the individual patient will not
receive the nutrition they truly need. However, we currently lack research on this point, making
it difficult to make the case for new policies and programs to serve clients at the household level.
To fill this gap, we propose that Senate Bill 2453 be amended to clarify that the Pilot may test
the provision of services at the household level.
Senate Bill 2453 Will Enhance the Ability of the Massachusetts Health Care System to
Provide Appropriate Nutrition Services Based on Patient Need
Senate Bill 2453 also presents a valuable opportunity to build upon existing programs to better
meet the full range of patient nutritional needs. Just this month, MassHealth began to implement
its Flexible Services program. Under the program, MassHealth Accountable Care Organizations
(ACOs) receive funding that can be used to meet the housing and/or nutrition needs of certain
patients. This innovative program represents an incredible leap forward in Massachusetts’s
ability to address the needs of some of its most vulnerable residents. However, it does face
certain limitations. First the program is limited to MassHealth ACOs, leaving health care
providers outside of the ACO system without funding to address the nutrition needs of their
patients. Second, the Flexible Services program places particular emphasis on serving
individuals with existing, significant illness, with little ability to include a focus on prevention.
And third, Flexible Services dollars are limited to meeting the needs of individual eligible
patients; they cannot be used to provide broader support to the patient’s household.
If enacted, Senate Bill 2453 would give Massachusetts the opportunity to build upon the Flexible
Services program, testing the impact of a comprehensive approach that fills these gaps. For
example, pilot participants could include health care entities that do not currently participate in
an ACO. Additionally, ACOs could use pilot funds to build upon their Flexible Services efforts,
expanding the range of nutrition services provided and populations served to meet the
requirements of the Food and Health Pilot. Finally, with the amendment described above, the
Pilot could go further in building upon the Flexible Services program by testing the impact of
providing services at the household level.
Building upon the Flexible Services program in this way would provide valuable data that could
be used to refine the Flexible Services program as it moves forward. This data will be critical as
the state works toward its upcoming renewal of its Medicaid Section 1115 Demonstration
Waiver.
Senate Bill 2453 Will Expand Access to Food is Medicine Interventions
Finally, if enacted, Senate Bill 2453 will provide both funding and data that can be used to
support the fundamental goal of the State Plan—expanding access to Food is Medicine services
so that all Massachusetts residents have access to the foods they need to heal and thrive. Across
the Commonwealth, many communities lack access to any Food is Medicine interventions.
Funding remains a critical barrier to scaling Food is Medicine interventions to meet current need.
5
In surveys conducted to develop the State Plan, almost half of responding nutrition service
organizations identified lack of funding as a barrier to providing Food is Medicine interventions.
Furthermore, only 18% of these respondents said they received any funding through contracts
with health insurers or health care partners, leaving the vast majority of these organizations
reliant on donations and grants to support their Food is Medicine programs.

We know that health care providers and health care payers across the state are increasingly
interested in addressing the role that food insecurity and diet play in the lives of their patient
populations. But in order to take real action and create real partnerships to meet these needs, the
health care sector continues to ask for data—proof that providing these services will accomplish
their goals of cost-effectively improving patient health. While initial studies have been helpful in
this regard, a large comprehensive study like the one outlined in Senate Bill 2453 would go
significantly farther in making this case.
We therefore support Senate Bill 2453 because it stands to provide opportunities to improve
access to Food is Medicine interventions in both the short and long-term. First, it will provide
concrete, direct funds that can be used to expand current programs to new populations and
geographies under the Pilot itself. But second, and perhaps more importantly, it will provide
critical data that can be used as the foundation for policies and partnerships that support
expansion on a much broader scale.

The Harvard Law School Center for Health Law & Policy Innovation and Community Servings
thank you for the opportunity to provide comment on Senate Bill 2453. For all of the reasons
included here, we stand in strong support of this important legislation and the Food and Health
Pilot it describes.

Should you have any questions, please contact Katie Garfield at
kgarfield@law.harvard.edu or Jean Terranova at JTerranova@servings.org.

Thank you for your time and consideration.

Sincerely,

Organizations

Center for Health Law and Policy Innovation
Katie Garfield JD, Clinical Instructor
Community Servings
David Waters, CEO
About Fresh
Adam Shyevitch, Chief Program Officer
Massachusetts Academy of Nutrition and
Dietetics (MAND)
Melanie M. Mott, PhD, RD, President
Children’s HealthWatch at Boston Medical
Center
Rich Sheward, Director of Innovative Programs
Massachusetts Food Systems Collaborative
Winton Pitcoff, Director
Delicious Living Nutrition
Dianna Carpentieri MS, RD, LDN
Nicole Cormier, RD, LDN
Massachusetts Medical Society
Maryanne Bombaugh, MD, MSc, MBA, FACOG
President
Kathryn Brodowski, MD, MPH, Vice Chair,
MMS Committee on Nutrition and Physical
Activity
Elder Services of the Merrimack Valley
Jennifer Raymond, Chief Strategy Officer
Franklin County Food Council
Jessica O’Neill, Chair
Project Bread
Jen Lemmerman, Director of Government Affairs
Hill Nutrition Consulting, LLC
Joan C. Hill, RDN, DCES, LDN, Founder/CEO
Sustainable CAPE- Center for Agricultural
Preservation & Education
Francie Randolph, Founding Director
Island Grown Initiative
Noli Taylor, Community Food Education Director
Victory Programs, Inc.
Meg von Lossnitzer, Director of Victory
Prevention
Just Roots
Jessica O’Neill, Executive Director
Individuals*
Sarah Andrus MS, RD, LDN
Public Policy Coordinator, Massachusetts
Academy of Nutrition and Dietetics (MAND)
Alan Balsam PhD, MPH
Public Health and Community Medicine
Tufts Medical School
Alexis Babaian
MA/MS Candidate, Friedman School of Nutrition
Science and Policy, Tufts University
Renee Barrile, RD, PhD
Associate Teaching Professor
University of Massachusetts Lowell
Mandilyn Beck
Sustainability Director, Sodexo at Partners Health
Care
Tracy Mangini Sylven, CHHC, MCHES
Director, Community Health and Wellness,
Brigham and Women’s Faulkner Hospital
Nicole Chenard MS, RD, LDN Elizabeth Metallinos-Katsaras PhD, RD
Department of Nutrition, College of Natural
Behavioral and Health Sciences
Simmons University
Meredith Goff CNM, MS
Sustainable CAPE
Leslie Parsons-Shuqom RN, BSN, CCM
Senior Clinical Consultant
Tufts Health Plan
Matt Haffenreffer
Process, Data, and Analytics Consultant
About Fresh
Rosanne Prim
Founder/CEO
Clean Plate Law
Liz Hatzenbuehler, RDN Susan L Richards, RDN, LDN, MS
Health and Wellness Consultant, SL Richards
Nutrition Consulting
Eliza Howlett, MS
Research and Evaluation Coordinator, ACO
Research Team, BMC
Jennifer Stiff
Nutrition Program Director
Minuteman Senior Services
Catalina Lopez-Ospina
Director, Mayor’s Office of Food Access, City of
Boston
Anna Tourkakis NDTR, MPA/H
Founder, Eating from Within Nutrition
Samantha Tweedie
MS/MPH Candidate
Friedman School of Nutrition Science and Policy,
Tufts University

1 Massachusetts Dep’t of Public Health, Chronic Disease Data, https://www.mass.gov/chronic-disease-data (last
visited Sept. 10, 2019).
2
John T. Cook et al., An Avoidable $2.4 Billion Cost: The Estimated Health-Related Costs of Food Insecurity and
Hunger in Massachusetts, CHILDREN’S HEALTHWATCH & GREATER BOSTON FOODBANK, (Feb. 2018).
Note that we have excluded special education costs in our calculation of $1.9 billion based on our focus on the
health care system.
3
John T. Cook et al., An Avoidable $2.4 Billion Cost: The Estimated Health-Related Costs of Food Insecurity and
Hunger in Massachusetts, CHILDREN’S HEALTHWATCH & GREATER BOSTON FOODBANK, (Feb. 2018).
Note that we have excluded special education costs in our calculation of $1.9 billion based on our focus on the
health care system.
4 Seth A. Berkowitz et al., Association Between Receipt of a Medically Tailored Meal Program and Health Care
Use, JAMA Internal Medicine, (2019).
5 Seth A. Berkowitz et al, Meal Delivery Programs Reduce the Use Of Costly Health Care In Dually Eligible
Medicare And Medicaid Beneficiaries, HEATLH AFFAIRS, (2018).

8

6 Hilary Seligman et al, A Pilot Food Bank Intervention Featuring Diabetes-Appropriate Food Improved Glycemic
Control Among Clients in Three States, HEALTH AFFAIRS, (2015).
7 Valerie Tarasuk et al., Association Between Household Food Insecurity and Annual Health Care Costs. CAN
MED ASSOC J, (2015).
8 Seth Berkowitz et al., Food insecurity, health care utilization, and high cost: a longitudinal cohort study. AM J
MANAG CARE, (2018).
9 Mary E. Morales et al., The Relationship between Food Insecurity, Dietary Patterns, and Obesity, CURR NUTR
REP, (2016).
10 Victoria L. Mayer et al., Food insecurity, coping strategies and glucose control in low-income patients with
diabetes. PUBLIC HEALTH NURITION, (2016).
11 Margot B. Kushel et al., Housing instability and food insecurity as barriers to health care among low-income
Americans, JOURNAL OF GENERAL INTERNAL MEDICINE, (2006).
12 Dena Herman et al., Food insecurity and cost-related medication underuse among nonelderly adults in a
nationally representative sample. AMERICAN JOURNAL OF PUBLIC HEALTH, (2015).
13 Patience Afulani et al., Food insecurity and health outcomes among older adults: The role of cost-related
medication underuse. JOURNAL OF NUTRITION IN GERONTOLOGY AND GERIATRICS, (2015).
14 Chadwick Knight et al., Household food insecurity and medication “scrimping” among US adults with diabetes.
PREVENTATIVE MEDICINE, (2016).
15 Nancy S. Weinfield et al., Hunger in America 2014. Prepared for Feeding America, (2014).
16 Molly Knowles et al., “Do you wanna breathe or eat?”: Parent perspectives on child health consequences of food
insecurity, trade-offs, and toxic stress, MATERNAL AND CHILD HEALTH JOURNAL, (2016).
17 Mary E Morales et al., The Relationship between Food Insecurity, Dietary Patterns, and Obesity, CURR NUTR
REP, (2016).
18 Adam Drewnowski. Obesity, diets, and social inequalities, Nutrition Reviews, 67(Supplement 1), (2009).
19 Kathryn Edin et al., SNAP Food Security In-Depth Interview Study, USDA, FNS, ORA, (2013).
20 Hilary K. Seligman et al., Food insecurity and glycemic control among low-income patients with type 2 diabetes.
DIABETES CARE, (2012).
21 The medically tailored meal provider in this study was Boston-based Community Servings. Seth A. Berkowitz et.
al, Association Between Receipt of a Medically Tailored Meal Program and Health Care Use, JAMA Internal
Medicine, (2019).
22 Hilary Seligman et al, A Pilot Food Bank Intervention Featuring Diabetes-Appropriate Food Improved Glycemic
Control Among Clients in Three States, HEALTH AFFAIRS, (2015).
23 Richard Bryce et al, Participation in a farmers’ market fruit and vegetable prescription program at a federally
qualified health center improves hemoglobin A1C in low income uncontrolled diabetic, PREVENTATIVE
MEDICINE REPORTS, (2017).
24 Hilary Seligman et al, A Pilot Food Bank Intervention Featuring Diabetes-Appropriate Food Improved Glycemic
Control Among Clients in Three States, HEALTH AFFAIRS, (2015).
25 Hilary Seligman et al, A Pilot Food Bank Intervention Featuring Diabetes-Appropriate Food Improved Glycemic
Control Among Clients in Three States, HEALTH AFFAIRS, (2015).
26 Hilary Seligman et al, A Pilot Food Bank Intervention Featuring Diabetes-Appropriate Food Improved Glycemic
Control Among Clients in Three States, HEALTH AFFAIRS, (2015).