This is a transcript of the Gastropod episode, Prescription Dinner: Can Meals Be Medicine?, first released on October 25, 2022. It is provided as a courtesy and may contain errors.

NOE GARCIA: It’s going to be Victor F, he is 52 years old and he is one of our clients and he’s on end stage renal disease. So he is on our no red meat diet with a regular breakfast bag and a fresh fruit bag. We’re going to come on all over and deliver him some meals.

[DOG BARKS]

[DOOR CREAKING OPEN]

GARCIA: Hello! Hey, how’s it going?

VICTOR: How’s it going?

GARCIA: Got your breakfast bag. How you doing today?

CYNTHIA GRABER: One hot day this summer, Nicky and I drove across town in Los Angeles to join Noe Garcia as he brought a week’s worth of meals to Victor. Noe works for an organization called Project Angel Food.

NICOLA TWILLEY: And Project Angel Food is one of a handful of organizations around the US that have been pioneering a new form of medical treatment: meals. Not just any meals, but medically tailored meals—meals that are specifically, nutritionally designed to help treat chronic diseases.

GRABER: And of course because we’re Gastropod, and we love food, we wanted to find out if using food as medicine works. Yes, you are listening to Gastropod, the podcast that looks at food through the lens of science and history, I’m Cynthia Graber—

TWILLEY: And I’m Nicola Twilley. And this episode: can a meal really be something your doctor prescribes and your insurance pays for, like a drug? Is food really that effective?

GRABER: And if a meal can be prescribed like a drug, then how does it work? Like how do you get a prescription for food, who fills it, who pays for it, and how could that be rolled out for millions of people across the country?

TWILLEY: This episode, we are diving into the hottest topic in both food and medicine: food as medicine. This episode is supported in part by the Burroughs Wellcome Fund, in support of our coverage of biomedical research, and by the Alfred P. Sloan Foundation for the Public Understanding of Science, Technology and Economics.

GRABER: Gastropod is part of the Vox Media Podcast Network, in partnership with Eater.

[BREAK]

JOHN GORDON: This one is, let’s have a look. Oh, this one’s Mongolian beef. We got some ginger in there. Then you got a little, red pepper, dry red pepper. Of course the beef. And then, you know, your salt, your pepper, a little garlic. The real kick to it is that ginger.

TWILLEY: John Gordon is the executive chef at Project Angel Food. He started out as a dishwasher nearly 30 years ago, and today he’s responsible for making hot meals for two thousand five hundred clients all across Los Angeles, every day.

GORDON: So, this category is our heart healthy, which is the largest category. And, this one’s good, actually. I really like this. I tried some yesterday,

GRABER: Every day at Project Angel Food, John oversees chefs and volunteers who make buckets and buckets of dishes like Mongolian beef and turkey chili and sweet and sour tofu. It all happens in a big industrial kitchen, and there were a good couple dozen people efficiently preparing and packaging up all those meals.

TWILLEY: The Mongolian beef had been cooked and frozen yesterday, that was being packaged to get sent out. They were cooking the turkey chili when we were there—it was almost ready for the blast freezer, and it would go out tomorrow.

GORDON: I call it double Dutch. So it’s kind of like (rhythmically) you cook today, pack tomorrow, cook today, pack tomorrow.

TWILLEY: Cooking more than 2,000 portions of Mongolian beef sounds like a challenge to me, but that’s not even the half of what John is dealing with. Remember, these are meals that are designed as a medical treatment, so they have to specially tailor them for clients with different diseases.

GRABER: And just to be clear, we’re focusing on using food as treatment, not as prevention. You’ve all heard that eating well can help keep you healthy and help prevent diseases like diabetes, but that’s a totally different story. You’ve also likely heard that having enough food and being able to afford good food is also essential to being healthy, but that’s also not the focus of this particular movement.

TWILLEY: This movement, the one we’re focusing on this episode, is a nationwide movement to prescribe and provide nutritionist-designed meals as a medical treatment to help keep patients out of hospital. They’re called medically tailored meals or MTMs for short.

ALISSA WASSUNG: It’s really more than a meal. It’s an intervention.

GRABER: Alissa Wassung is executive director of the Food is Medicine Coalition. Project Angel Food is one of the coalition’s members, there are others in San Francisco and Philadelphia and New York and Boston. Alissa says that the meals that these organizations provide are critical for a very specific population in need, people who have chronic conditions and end up back in the hospital again and again.

WASSUNG: We are really concentrating on the 5 percent of people who are costing 50 percent of our healthcare budget. Those who are really in a vulnerable position and need this extra support. It’s not food for everybody.

TWILLEY: Specifically, it’s for people who have chronic conditions that can be treated with food. Like diabetes, pre-diabetes, cardiovascular diseases, kidney disease and kidney failure, or they’re getting chemotherapy or radiation. And they can’t manage the nutritional needs of these conditions on their own.

GRABER: Various diseases are grouped together when it comes to meals, like diabetes and cardiovascular disease patients both get heart healthy meals, people with gastric reflux and also people who are getting treated for cancer both might get meals for people with digestive issues. And then each category gets their own version of each dish.

GORDON: Well, the recipes are different. One of the main things with the chronic kidney disease is that we give ’em less protein. And the way this is mapped out is say, like, if I come up with a recipe and I shoot it to our nutritionist, she’ll go through the recipe and she’ll make the necessary adjustments so that it’s suitable for our clients’ categories.

GRABER: One of those nutritionists is Max Schroder. She told us that Mongolian beef recipe might have gone through a bunch of different tweaks.

MAX SCHROEDER: So depending on whether the client is a heart healthy client, whether the client has diabetes, kidney disease, liver disease, cancer. Then we just start adding things, taking away things.

TWILLEY: These tweaks are based on specific guidelines for treating each disease—how much of different nutrients you should consume to not exacerbate your condition but also hopefully to improve it. So the protein issue that John was talking about in the dishes for patients with kidney disease—that’s based on treatment guidelines from the National Kidney Foundation.

SCHROEDER: So if you are not on dialysis yet, and your kidneys are not very strong, then you really want to be gentle with your kidneys and start watching out for high potassium, high phosphorus, too much protein.

GRABER: But those guidelines change when the patient is strong enough to be on dialysis, which acts as a kind of external kidney, regularly cleaning their blood.

SCHROEDER: When a client gets on dialysis, the dialysis can pull protein from the blood. And so we want to start giving them more protein. And so with kidney disease, it’s, you know, it’s one side or the other. And so there’s two different meal plans for that.

TWILLEY: If your kidney disease is really advanced, what they call end stage kidney disease, your diet is really constrained, so that’s a tough one. You can have apples but not apricots, and carrots but not pumpkin—it’s complicated.

GRABER: That’s because of the specific nutrients in those foods. The patients’ kidneys can no longer handle levels of calcium, potassium, and phosphorus that people without kidney disease have no problem with. So those particular minerals are really carefully controlled in this diet.

TWILLEY: Like for example, with John’s turkey chile verde recipe? For most of the clients, they make it with a side of brown rice, but for the kidney disease patients, they have to switch that for white rice to keep phosphorus levels down. That kind of really precise balancing of specific nutrients—that’s something that would be really hard to figure out yourself.

GRABER: Some things are more straightforward and you don’t need to understand the precise minerals in particular foods, but it’s still hard to do. For patients with diabetes, they need plenty of vegetables, not a lot of carbohydrates, they have to watch their portion sizes. Patients with digestive issues can’t eat a lot of foods, like tomatoes and onions and berries and citrus. They also can’t eat a lot of strong flavors or spices, and that’s true for cancer patients, too: strong spices can be really difficult for them.

TWILLEY: There’s always back and forth—John will ask Max if he can add some thyme maybe, or some lemon, to boost up the flavor. After all, the most precisely medically tailored meal in the world is only going to be any use if the client actually eats it. They have to taste good.

GORDON: And then we’ll come down here and we’ll do the acid test, kitchen wise, as far as like, all right, let’s cook them all off, line them up and taste test them. And then all the chefs on the floor will walk down the line, taste testing. Everybody will make notes. Generally things tend to be… bland, but it’s to be expected. But the reach is to give it as much flavor as possible without compromising the nutritional value. And then once it makes it through the acid test, then of course it’s the financial side of it, making sure that we can secure the ingredients at an affordable price. And then it gets worked into the rotation.

TWILLEY: Some things just don’t work out—lettuce doesn’t freeze well, so that’s a no. Some things are too fiddly—the team doesn’t have the resources to pinch together thousands and thousands of homemade dumplings, for example.

GORDON: Like if we had to make… some kind of crepe, that was really delicious, really light, really nutritionally, you know, on point for all categories, but to actually roll—it would probably be two per client. So, you know, to roll 6,000 crepes. Yeah. Which we’re just not going to be able to do it. So it won’t even make it out the gate of consideration. But we might take all the ingredients from inside the crepe and see, can we build from there?

TWILLEY: It’s a challenge, but it’s one that John and his team regularly succeed at. Richard Ayoub is CEO of Project Angel Food, and he told us he sometimes eats the meals himself.

RICHARD AYOUB: You know, sometimes our clients will call and say, oh my God, it feels like I just went to a fancy restaurant. [LAUGHS] You know, that’s the biggest compliment we can get. And it’s very hard to make a meal where you’re taking out so much, make it feel flavorful and taste good and smell good too.

GRABER: As we’ve said, these carefully crafted meals are sent every day to people around Los Angeles, and those clients really need Project Angel Food’s help.

AYOUB: So, as of today, 98 percent of our clients are living at or below the poverty level. So these are people who have an illness. They’re home-bound. And this is an illness that prevents them from shopping and cooking for themselves. So for instance, if they have lung problems, they probably are attached to an oxygen machine. If they have kidney problems, they’re going to dialysis. They could be bed-bound, could be in a wheelchair. They could be in the walker. Seventy-seven percent are people of color. And more than 60 percent are over the age of 60.

TWILLEY: You can see how eating healthily, let alone carefully balancing micronutrients, could really be impossible for this population. But eating badly is making them sicker—and it’s sending them to hospital.

AYOUB: They are what they call frequent flyers. The highest utilizers of healthcare. And cost the system the most amount of money.

TWILLEY: And in the US, most of them—because they’re not able to work, because they’re elderly, because they’re poor—they’re on Medicare or Medicaid.

GRABER: Medicare and Medicaid are government programs that provide health insurance to seniors and disabled individuals and low-income people, these are people who might not be working and so they can’t get insurance from their employers, or their employers don’t provide it. And most Americans get their insurance at their jobs. Yes, we know, this is most definitely not the ideal way to get health insurance.

TWILLEY: Do not get me started. I miss the NHS.

GRABER: So Richard introduced us to who his clients are in general, and Max and John told us what difference the food makes in theory, but we wanted to meet with a client and see this type of medical treatment in action. That’s coming up after the break.

[BREAK]

VICTOR: This is usually the cereal. [CRINKLING PLASTIC] And the fruit and the raisins.

[CRINKLING PLASTIC]

VICTOR: I usually get my string cheese, which is one of my favorites too. And then the fruit, and then they give you yogurt. Then this is the oatmeal.

GRABER: We visited Victor in his small apartment in central LA. He first unpacked his breakfasts and his snacks, and then he got to his favorite part, the full meals.

VICTOR: Nice pre-packed, you know, frozen wraps. This is the, this is the favorite, the roasted chicken. And it has the peas, and it has a little bit of rice. This is the… African Curry chicken. I haven’t tried this one. And this one is… turkey patties. Pretend it’s a hamburger patty. With the cauliflower and the corn. They’re like, perfectly portioned and just ready to go. Three minutes in the microwave and I’m eating.

TWILLEY: As we hung out, Victor stashed his meals in the freezer. He’d just got back from the doctor’s. He told us he’d struggled with diabetes for thirty years, and that had contributed to a lot of other chronic conditions, and then he got cancer.

VICTOR: Yeah, I’m a cancer patient. Been fighting cancer for 13 years. And then I lost my kidney. I lost all my toes on my left foot. It was just a long battle.

GRABER: Victor needed a new kidney, he needed a transplant, but he couldn’t get one. His weight and his diabetes weren’t under control. He’d never been able to manage the diabetes himself, even after help from nutritionists, so things weren’t looking good for him. Until he met Project Angel Food.

VICTOR: I was actually connected through my social worker in one of my hospital stays. So I don’t know how the protocol worked, but they—they got me in contact and that was like a godsend. They were literally like a godsend.

TWILLEY: Before, Victor had relied on his son to bring home food, and honestly, often it was fast food. That’s what Victor liked, and it was cheap and easy. The Project Angel Food meals were a little bit of a shock to his system at first.

VICTOR: This is like a balanced meal. So it’s like, kind of—hard to get used to it, to be honest with you, like, oh, okay, well this is this, this is this.

GRABER: He got a quiche in one delivery and he’d never even heard of that before. But really, one of the biggest surprises to Victor when he unwrapped his first meal was the size. He was used to maybe multiple hamburgers for a meal.

VICTOR: You know. And it’s like, when I first saw it, I was like, psssh, like I’ll eat three of these right now.

TWILLEY: Also, even for something that looked familiar, like chicken, the flavors were often really unfamiliar.

VICTOR: Stuff with like, herbs and like lemon, like spices, you know, food that was like, prepared, like, you know, in the kitchen, like restaurant style, but not like Burger King or, you know. [LAUGHS] So that, getting used to those spices and the vegetables, you know, it’s just… my taste buds didn’t care for it, but in my mind, I knew, you know, by the doctors that I needed it. So it’s just, you know, mind over matter. So. And now it’s like, you know, I couldn’t believe I was eating the other way. [LAUGHS]

GRABER: Victor told us he loves the taste of the food now, he particularly loves the roast chicken. And one meal now totally fills him up. But most importantly, these meals worked.

VICTOR: Yeah. Yeah. It changed my, my—physically it changed, and blood work changed. And to the point where I got a transplant, you know. Before I was too heavy, it was like, no, you’re not a candidate. You know, not to be over exaggerated, but it did, it literally saved my life because you know, it helped me change my mindset of portion-wise and you know. So whoever set me up completely, I, you know, I’ve, I’ve never been able to find the person to thank them, but it is really, you know, it is a godsend. It is very helpful.

TWILLEY: Victor has been receiving his medically tailored meals from Project Angel Food for three years now. Some clients stay on the program for longer, but Richard told us that the average is about a year and a half.

AYOUB: Some roll off sooner. And when we get a call saying, I’m feeling better. In fact, we got one the other day from this woman who said, I’m feeling better. I’m learning how to cook on my own. And I’m moving around more. Please give it to someone else who’s sick. These people are so grateful for the program. They don’t want to abuse it.

GRABER: And those clients who leave the program, they often come back to say that they’ve really learned, that they’ve changed how they eat.

SCHROEDER: I often tell the clients: keep that box. The meal box. Because it has the correct proportions of starch, vegetable, and entree. And so they do, and some of them even make batches of meals themselves. And reuse the containers and just put it in a plastic bag in the freezer.

TWILLEY: Meeting Victor, you really feel the power of these medically tailored meals to change the course of someone’s disease—and their life. But even though this meal treatment program seems to work, it’s still a completely foreign concept for most of the medical establishment.

GRABER: Sanjay Basu is head of clinical care at an organization called Waymark Care, they specifically work on improving treatment and health outcomes for patients who are on Medicaid. He says when he started out as a doctor, one of the ways he failed his patients was by not thinking of food.

SANJAY BASU: I remember seeing a patient in residency who was always labeled the problem patient. And would have many visits to the emergency room for preventable complications of their diabetes. And he would swear up and down that he’s taking his insulin, he’s taking his medications. And he was right.

TWILLEY: But this patient was on food stamps, what’s now called SNAP benefits. And those are given out at the start of the month.

BASU: By the end of the month, he would run out of food, but still be taking his insulin. So his sugars would dip too low. And it’s not something that in medical school, we’re trained to think about—this connection between social and economic factors and what we’re doing, in terms of medications and focusing on prescriptions and labs and so forth. And so that was an important learning period for me to understand what was really going on for him. And, kind of how myopic I was being, in focusing on the drugs.

GRABER: That story is really a food insecurity story, and that’s one of the ways that food and health overlap.

TWILLEY: But what it shows is that doctors are typically not trained to think about food as part of medical care. And Sanjay thinks that’s a big mistake.

GRABER: After that experience, Sanjay became interested in all the ways food can help his patients get better and stay healthy. Today, he’s also one of the researchers studying MTMs to see if they actually work.

TWILLEY: Because, while visiting with Victor was enough to convince us, it’s just one person’s experience. And that’s what scientists call anecdata, stories, not actual data from rigorous scientific studies. That’s what was missing.

SETH BERKOWITZ: And so it was something that seemed very plausible. I mean, you hear about it and you immediately think, yes, this is likely to improve people’s health. But there wasn’t a lot of that quantification of, well, how much does it improve health? In what situations, how long do you need to receive it for? That kind of thing.

TWILLEY: Seth Berkowitz is trained as a doctor and he is a professor of medicine at UNC Chapel Hill. Like Sanjay, these days he’s deeply involved in getting that evidence base for medically tailored meals as an effective medical treatment.

GRABER: You might think, why do you need to do a big scientific study? Isn’t it obvious that these meals should be helpful, and they certainly couldn’t hurt? But the problem is, budgets are limited, this is a very intensive program, and the money that gets spent on MTMs is money that isn’t being spent on a different healthcare program. So you really need to know that it works before you spend money on it.

TWILLEY: For MTMs, what “working” means is, yes, improving health outcomes, but also saving money. Which is actually a little unfair, because saving money is not the standard that other, more traditional medical treatments are held to.

BERKOWITZ: So, you know, for pharmaceutical interventions, if cost -effectiveness is evaluated at all, it’s generally way down the line. It’s, you know, by law, not part of coverage decisions in Medicare, for example, and things like that. And so there, the real standard is, does something improve health? The FDA approves drugs if they’re safe and efficacious for a particular indication. And I think that’s the right way to do it.

GRABER: I obviously agree—and it sounds kind of messed up that medically tailored meals aren’t evaluated the same way as medicine is. This is all part of the story of how the very complicated American healthcare system sucks. But to at least explain this angle of it, Medicare and Medicaid have specific budgets from the government, they have to live within those budgets, and so thinking of a new treatment as a budget item, well, that’s what it is. But that’s why studies look at both outcomes.

TWILLEY: Over the past few years, Seth’s been involved in a number of studies looking at MTMs. To start with, he had a very basic question: does providing MTMs to someone actually change how they eat? Answer: yes.

GRABER: So then the next question Seth asked was, do those changes in the patients’ diets affect their health? And the answer to that was also, yes. They made a big difference to health outcomes.

TWILLEY: And then the final question is, does this save money? Remember, this is a group of people that goes back to hospital repeatedly. So do the people who get MTMs go to hospital less frequently—do MTMs save money? That’s something Sanjay has looked at.

BASU: So, you know, we and other folks studied groups of patients who got access to these medically tailored meals and those who were on waiting lists for those meals. And those who got early access by kind of winning a lottery in order to start the program, while others have waited on the waiting list, did much better first in terms of their diabetes. You know, in the studies we conducted, we would typically say that we could prevent about one in every 14 hospital admissions for a person with diabetes who had complications. But then the same findings in terms of high blood pressure, heart failure, and interestingly cancer as well, which is one area where I didn’t fully appreciate until seeing the results, just how much having nutritional support during the periods, particularly of chemotherapy and radiation therapy, really made a difference.

TWILLEY: In similar studies, Seth has found similar results: that the group who receive the medically tailored meals have fewer inpatient admissions and fewer emergency room visits—70 percent fewer! And while providing medically tailored meals is not free, hospital visits in the US are bankrupting.

AYOUB: Generally, if we just, if we do the registered dietician, if we do the chef preparing the meals and we do the delivery of it, it’s around $11. Per person, per meal, per day. And then if you compare that to staying in the hospital, it is a savings of thousands of thousands of dollars.

GRABER: Seth saw those savings in his research.

BERKOWITZ: And so, the effects were large. There was in general on the order of maybe 20 percent lower spending or so.

GRABER: Great, these programs work, and they save money! This all sounds pretty straightforward so far. But now, and you listeners won’t be surprised to hear that maybe this isn’t so straightforward, how do we roll these types of programs out to everyone who needs them? That’s coming up, after the break.

[BREAK]

TWILLEY: First of all, it’s important to say that not all the questions Seth and Sanjay and their colleagues have about medically tailored meals have been answered yet. One of the outstanding questions Seth wants to study is how many of someone’s meals need to be provided to get the best results. So Project Angel Food currently provides one full meal a day plus breakfast and some snacks.

BERKOWITZ: But it may be that you get even more benefits if you provide, you know, approximately someone’s entire intake. Or, you know, or somewhere in the middle or something like that. So, questions about what the dose is.

GRABER: Another question Seth has is, well, maybe part of the reason these work so well is they take the financial stress of buying good food away. Could it work just as well if the clients were given a subsidy for food instead of these tailored meals? He’s looking into that now.

TWILLEY: But even with these questions still open, both Sanjay and Seth say that we now know enough to say that for people with the kinds of chronic diseases that Project Angel Food serves, these medically tailored meals do work. The evidence they’ve gathered is strong enough to say that.

GRABER: And the scale of the impact might be bigger than we think it is. These studies are all relatively recent, and they’ve been able to see fairly quick changes in, say, diabetes patients.

BASU: A lot of the other results, the studies are still continuing because the results of changes in nutrition take years to manifest. So for example, we see lower blood pressures. But it’ll probably be seven or eight years to see a reduction in heart attack or stroke rates.

TWILLEY: So they might work even better than we think. That means that now the only challenge is figuring out how to get these meals to all the people who might benefit from them. NBD, right?

GRABER: Well the first question is really, what scale are we talking about? How many people could theoretically qualify for and benefit from programs like this?

BASU: That’s a sadly large proportion of patients in the United States. It’s not a small number of people.

BERKOWITZ: It’s a pretty large number. I mean, likely to be in the millions of people.

TWILLEY: Just to be clear, these meals are not for every single person in America with these chronic diseases—if you have the resources to manage your diet yourself, great, you don’t need medically tailored meals delivered to you. On the other hand, if you don’t have a freezer, you can’t benefit either, however useful it would be. That locks out people who don’t currently have shelter, for example.

GRABER: But these programs do still need to be rolled out far more extensively than they are right now. Which raises another question: Who’s going to take this on?

WASSUNG: All of the agencies that are part of the Food As Medicine Coalition, medically tailored meal agencies, were actually founded at the height of the AIDS pandemic almost 35 years ago.

TWILLEY: We’re talking about two dozen nonprofits, mostly located in cities with larger gay populations: New York, San Francisco, Minneapolis, Philadelphia, Miami.

WASSUNG: And they were founded really through volunteer efforts to nourish people who were then dying of AIDS in their homes.

GORDON: Back then, the emphasis was on: put weight on them and keep weight on them.

GRABER: John remembers all the different ways they tried to pack the calories on for people with AIDS who were wasting away, technically it’s called AIDS wasting syndrome. John and his team made brownies and coconut cake and three different kinds of mac n’ cheese. And they were serving these meals to people who at the time were shunned, a surprisingly large number of people were afraid of even touching AIDS patients.

GORDON: So, you know, at a time when they most needed people, they just didn’t have anyone in their corner. And so it was, you know, difficult to get up and cook or impossible to get up and cook. And so, here comes Project Angel Food, like, hey, here’s a hot meal per day. Guaranteed. We got you.

TWILLEY: Fortunately, these days, the AIDS crisis in the US is much more under control and the stigma and hysteria around the disease has calmed down. By the mid 2000s, the need that Project Angel Food was set up to address wasn’t so pressing anymore. Richard told us, it had become clear that they had to make a decision about the organization’s future.

AYOUB: So that brave board of directors said, let’s start helping everyone else who needs a special meal.

GRABER: Project Angel Food already had nutritionists on board, so then they just had to figure out how to provide the best possible meals to other people who those meals could really help. And they weren’t alone in that shift.

WASSUNG: Today, fast forward, 35 years. Most of these agencies have expanded their missions as the trajectory of HIV changed, and now serve people living with all sorts of chronic and severe illnesses.

GRABER: Richard is proud that his organization serves thousands of people every month, but he wants to grow and serve even more Angelenos. There’s a huge unmet need in Los Angeles.

TWILLEY: But even if Project Angel Food does scale up to serve everyone who needs medically tailored meals in Los Angeles, that’s still the tip of the iceberg. After all, not everyone lives in LA.

WASSUNG: We are not covering the country the way that people need us to be doing. And to do that, though, we need to make some fundamental changes to where it’s accessible. Right now, it is highly dependent on where you live, whether there’s a medically tailored meal agency in your backyard, whether that medically tailored meal agency is in partnership with a healthcare reimbursement structure that allows them to support all who come to them in need.

GRABER: The problem is, the organizations who have been doing this have been around for decades. How do you copy something that grew organically like that and create it from scratch in a new city, or maybe in an even more challenging and spread-out location, in a rural area?

TWILLEY: This kind of challenge is Alissa’s bread and butter. The Food is Medicine Coalition is on it.

WASSUNG: We also have a really amazing program called the Food As Medicine Coalition Accelerator. And through the accelerator, we’re raising up nonprofit community-based organizations in areas where there is no access and teaching them to do what we do.

TWILLEY: Richard told us he’s mentoring six new programs within the Food is Medicine Coalition. And Sanjay told us about another initiative.

BASU: I think an important path forward is to share an open source playbook of how to set up a medically tailored meal program. And there’s some colleagues who are working on that, particularly within the North Carolina medically tailored meal program context.

GRABER: There are even initiatives about how to codify things and make it easier to implement among the insurers, like how to make the billing codes the same all around so everyone knows what they’re paying for.

TWILLEY: Paying for it—that’s the biggest question of all. Right now, Project Angel Food and all its sister organizations—they started out as charities and they still are. They rely on donations, fundraising, philanthropy—that’s how they do what they do. To scale up, they need to go beyond that—they need insurers and the government to reimburse them for providing a medical treatment.

GRABER: And that’s starting to happen these days. In 2018 a California state senator visited one of Richard’s sister organizations, and he realized this was something that could save the state money on healthcare costs. But he knew his colleagues in the government needed proof that it worked—they needed data that showed that medically tailored meals, or MTMs, help people get better, and that they keep people from needing other more expensive kinds of healthcare.

TWILLEY: But wait, I hear you say—Seth and Sanjay were already doing these studies. Surely the Californian legislators could just talk to them? But politicians need pilot studies. It may be redundant, but it’s just how things work.

AYOUB: And they said, oh my God, we need to do a state pilot. Needs to be millions of dollars. Phone calls came in. We immediately said yes.

TWILLEY: Richard and his colleagues around the state started making visits to the legislators in Sacramento.

AYOUB: Every single office we visited said, you know what? This is a great idea, but don’t be surprised if it doesn’t go through. And then, it made the budget. And we’re like, oh my God, we did the impossible.

GRABER: But they couldn’t celebrate yet—in theory the governor could still strike a red line through that budget item and get rid of the pilot program entirely. Richard and his team were on the edge of their seats.

AYOUB: And then we heard on the news, the budget was approved and I’m like, were we redlined? Did we make it? We called our advocate. Are we in it? They said you’re in it. You got it.

GRABER: They got 6.3 million dollars for six nonprofits around California who were already involved in providing medically tailored meals. These nonprofits hadn’t had the resources to rigorously study the outcomes for their patients, this pilot would do that for a group of them.

TWILLEY: For the pilot, they picked MediCal patients with congestive heart failure. MediCal is California’s version of Medicaid, and these are patients who typically require the most healthcare interventions and thus end up costing taxpayers the most money.

GRABER: The pilot is now over and the results are in—but we don’t have the specifics for you, because they haven’t been published yet. But the early data on the healthcare outcomes and the savings were just what folks like the government representatives in California needed to include medically tailored meals as a benefit for low-income and senior patients.

BASU: A lot comes down to the budget. And so, we can say these nice things about patient outcomes. We can say some nice things about how people feel, and those are important. But giant asterisk, the budget really just matters so much to the pressures that policy makers are under. The moment we crossed that line, from being an initial investment to actually net saving money, was the moment where the conversations changed dramatically. And I would be naive to say that it was the testimony of people whose lives were changed. Honestly, at the end of the day, it was the Excel spreadsheet that made all the difference, for better or worse.

TWILLEY: For better in a lot of ways, because starting this year, in California, doctors whose patients are on MediCal as their insurance can prescribe medically tailored meals to patients who meet certain criteria, and those meals will be reimbursed by the state.

AYOUB: It’s called in California, because we always have to have fancy names for things, it’s called Community Supports. And so this is now what we’ve always wanted. It’s embedded as a benefit of MediCal or Medicaid.

GRABER: This is incredibly exciting—California is huge. And what happens in California often spreads around the country. But what’s also exciting is that California is not alone here—New York and Massachusetts also have programs that reimburse for medically tailored meals, North Carolina has some pilot programs. Like we said, it’s a movement.

TWILLEY: To take this from pilot to reality, there’s one more missing piece. And if you think government officials only care about Excel spreadsheets, you should meet the health insurers. They are all about the numbers.

WASSUNG: It was that research that really started to change the conversation about the value of this intervention. And it changed the conversation largely with healthcare insurers.

TWILLEY: So we went to speak to an insurer—he’s called John Baackes and he represents another player in the complicated US healthcare system. Medicaid and Medicare are insurance plans, but there are also independent companies that administer those plans and other private healthcare plans—and these are the insurers. Honestly it all makes my head hurt.

GRABER: John is CEO of LA Care health plan, it’s one of the biggest insurers in Southern California. To continue with the headache-inducing confusion, John is kind of an unusual insurer, because his healthcare plan in LA is not a normal for-profit business, it’s an organization that the California government created to help run the healthcare for Medicaid patients in the state, and it’s funded by the government.

TWILLEY: Another weird aspect of the U.S. healthcare system: Medicare and Medicaid are national programs but they’re actually operated on a state-by-state basis, which means individual states can all implement their programs slightly differently.

GRABER: John’s organization, LA Care, is responsible for insuring two and a half million people in Los Angeles. John knows he can’t exceed his government budget, but he’s not trying to make a profit, and he can test programs to improve healthcare even on a city-wide basis.

TWILLEY: Before he moved to LA, John was the CEO of a big healthcare plan in Philadelphia. And that’s where he got introduced to the idea of medically tailored meals. Project Angel Food has a sister organization in Philly called Manna.

JOHN BAACKES: We paid for a study that looked at the utilization of medical services by people who were receiving the Manna meals, which were also medically tailored. And the study was absolutely convincing, and this is 12, 15 years ago, that there was a correlation between treating food as medicine, prescribing meals to people that were nutritionally targeted at their health status. And we saw a precipitous drop in emergency room utilization, readmissions to hospitals.

GRABER: Before this study, John would never have considered reimbursing for meals, it just wasn’t on his radar.

BAACKES: When I was first introduced to the idea, it was like, oh, I never thought of that. [LAUGHS] And, when I saw the results of this study, which were amazing, I said, well, this is a no brainer. Why aren’t we doing this?

TWILLEY: This experience was all it took to convince John that the financially responsible thing to do as an insurer was pay for these meals. When he moved out to LA, he got connected with Project Angel Food pretty quickly.

BAACKES: Los Angeles is the largest county in the United States with 10 million people. So a quarter of the population is in our health plan.

TWILLEY: Which is a lot. And even before California decided to reimburse for medically tailored meals, John straight-up dipped into his reserves and gave Project Angel Food a grant to make sure that a bunch of his clients who really needed these meals got them.

GRABER: But like we said, since earlier this year, these meals are one of a number of things that the state will help pay for in their healthcare plan that aren’t actually drugs or medical procedures. All the things on that new list of community supports are important, they’re all critical pillars for someone on Medicaid. One of the things MediCal now can even pay for is getting someone housed. But to John, medically tailored meals are actually the quickest win.

BAACKES: Of all of the community supports that are out there, that is probably the one that has the biggest bang for the buck.

TWILLEY: John thinks that tens of thousands of his clients would qualify for medically tailored meals. They’re just not signed up yet.

BAACKES: Now, so when I say tens of thousands, if we said 10 percent of our members were eligible for it. That’s 250,000 people. And I don’t think it’s a stretch to think that 10 percent of our members may benefit from it.

GRABER: But there are a number of obstacles to getting people to sign up for these programs.

BAACKES: Well, number one, the providers don’t know about it, and the beneficiaries don’t know about it. As I like to say, Medicaid beneficiaries are not middle class folks. They don’t wake up in the morning thinking, oh, wow, it’s time for my annual mammogram. They wake up in the morning saying, do I have enough money to pay the rent?

TWILLEY: And even for the providers, John says it takes at least two to three years for awareness of new programs to spread through the system.

GRABER: Another issue is the predictable one of paying for these meals.

BAACKES: The amount we get reimbursed, the guideline that the state put out was a joke. [LAUGHS] They thought it was seven. Seven dollars!

GRABER: That’s way less money than it takes for food and all the services that Richard provides. He told us the meal prep and delivery alone costs about 11 dollars, but he says it costs another nearly 10 bucks per client per day to cover all of the services like the medical nutrition therapy. Either way, it’s a lot more than seven dollars.

TWILLEY: And that’s because Project Angel Food is doing more than just dropping frozen MTMs off for clients

AYOUB: It’s not like, Starbucks. You go there, you pick up your Starbucks and you leave. It is a registered dietician, works with our chefs to design the meals. The registered dietician talks to the client and gives them nutritional counseling. There’s a client services person who does the intake and who talks to the client on a regular basis when we’re delivering meals.

GRABER: And then there’s a delivery driver who sees the client every week, and they can tell in person if anything’s wrong.

AYOUB: That delivery could be the only human being that client sees in that week. And that human connection is really, really valuable.

TWILLEY: And that’s just not something you can do for seven bucks per patient per day.

GRABER: That potentially low reimbursement rate makes Richard nervous. Insurers may well just go to the cheapest organization offering MTMs, and unsurprisingly there are already for-profit companies springing up that are planning to provide medically tailored meals at a lower cost than he does. But they probably won’t do it with the nutrition counseling and the really important visits and even the same quality of food that Richard’s team provides.

AYOUB: And that’s my concern, is that they’ll charge so low for the meal, that the health plan will go for them. And this organization that’s been around for 33 years, that has provided their clients with meals for free, won’t get the reimbursement.

TWILLEY: This is a real concern. Shortchanging on these meals could easily defeat their entire purpose, but it’s a constant risk. Because even though in the grand scheme of things, these medically tailored meals are cheap, Medicaid is just so underfunded.

BAACKES: As someone once said to me, no politician has been elected running on a platform of: let’s pay more for Medicaid. Medicaid is not properly funded. And when you consider a third of the state of California is in it, it’s not right.

GRABER: But even so, even though we need more money for Medicare and Medicaid, these meals work and they save money, even at the more expensive rate that Richard and his fellow nonprofits provide. Just a couple of weeks ago, a new study came out that estimated that, if everyone who was eligible in the US received MTMs, in just the first year, the program would prevent more than a million and half admissions to hospitals and it would save an incredible $13.6 billion.

TWILLEY: So let’s roll them out nationwide already!

GRABER: Alissa Wassung said that’s exactly the goal of the Food is Medicine Coalition.

WASSUNG: Obviously number one is modernizing Medicare and Medicaid to make it a reimbursable service. That is, and will be our goal until it becomes a reality. And we can do all that we can do as nonprofit, medically tailored meal providers, but it’s the structural change that will really make a difference.

TWILLEY: And there are now signs that that might actually happen—just last month, at the big White House Conference on Hunger, Nutrition and Health, they issued a recommendation in favor of funding these meals and embedding them in law. That’s influential even though it’s just a recommendation.

GRABER: But there is actual national legislation moving forward too.

WASSUNG: We have a tremendous opportunity on the floor of Congress right now in HR 5370, which is the Medically Tailored Home-Delivered Meal Demonstration Pilot Act of 2021.

GRABER: I know we’re in 2022, but it was introduced last year. If this bill passes, medically tailored meals will be tested in at least ten states over the course of three years.

TWILLEY: And yes, it’s another pilot, when both Sanjay and Seth told us we have enough evidence.

GRABER: But this is what it takes to get something like this rolled out at this scale. And Alissa and Richard both expect that this larger pilot should show results as good as the ones they’ve seen in the past.

TWILLEY: So they’re hopeful that one day, not too, too, too far in the future, even new doctors, like Sanjay once was, will come into their practice knowing that they can prescribe food to help their patients get better.

AYOUB: My whole goal is that one day, just like a doctor writes a prescription for medicine. The doctor will write a prescription for medically tailored meals. It should be that common.

[MUSIC]

GRABER: Thanks this episode to Richard Ayoub, John Gordon, Max Schroeder, Victor, Noe Garcia, and all the other folks at Project Angel Food who helped us out. Thanks also to Sanjay Basu, Seth Berkowitz, Alissa Wassung, and John Baackes. We have links to everyone’s organizations and research on our website, gastropod.com.

TWILLEY: Also, we don’t often do this, but this issue is one where you can make a difference, if you live in the US. Pick up the phone and call your elected representatives, your congressperson and your senator. Tell them you’re a voter in their constituency and you want them to support HR 5370, the Medically Tailored Home-Delivered Meals Demonstration Pilot Act of 2021. If you want to do this we’ve got those links on our website too.

GRABER: Thanks also to our superstar producer Claudia Geib for all her help this episode. We’ll be back in two weeks with the story of America’s perfect tree and its lost nut. ‘Til then!