The inclusion of preventive medicine in Medicare, Medicaid, and CHIP

Since their establishments, Medicare, Medicaid, and CHIP have evolved to combat new challenges and to serve the expanding needs of their patient populations. Over the last two decades, these programs have evolved specifically to include more preventive medicine.Footnote ⁵⁹ Preventive medicine improves the welfare of patients and decreases the financial burden on the overall health system.Footnote ⁶⁰ In turn, this lower financial burden allows health providers to better allocate resources.

For example, in 2005, the Secretary of Health and Human Services (HHS) provided that “[s]eniors who embrace prevention can literally add years to their lives.”Footnote ⁶¹ In the same press conference, the Medicare administrator and heads of the American Cancer Society, American Diabetes Association, and American Heart Association expressed support for turning Medicare into a “prevention-oriented program” thereby “saving thousands of lives and billions of dollars in avoidable medical expenses.”Footnote ⁶²

In the years following, bipartisan groups worked to expand preventive medicine, and President Obama dramatically expanded preventive medicine in the Affordable Care Act (ACA).Footnote ⁶³ After the ACA, Medicare and Medicaid expanded to cover smoking cessation treatmentsFootnote ⁶⁴ and screenings that help providers to identify their patients’ diseases early.Footnote ⁶⁵ Today, Medicare, Medicaid, and CHIP cover a wide range of preventive services.Footnote ⁶⁶

How diet-related chronic diseases impact Medicare, Medicaid, and CHIP

Improving the diets of Medicare and Medicaid patients could drastically improve human welfare and reduce costs in already cash-strapped federal health programs. Presently, the U.S. spends more on medical care than any other country, and health expenditures continue to grow. Footnote ⁶⁷ Over the last fifty years, health care costs have risen for the nation from five percent of GDP in 1960 to nearly eighteen percent of GDP in 2016.Footnote ⁶⁸ Governments at the federal, state, and local level pay the majority of US health expenditures.Footnote ⁶⁹ As Medicare and Medicaid have grown to provide care to more patients, both programs have become major parts of the federal budget.Footnote ⁷⁰ In 2019, Medicare spent a total of $799.4 billion.Footnote ⁷¹ In 2020, Medicare had 62.8 million enrollees—54.5 million elderly and 8.3 million disabled persons.Footnote ⁷² The United States’ elderly population is estimated to considerably increase over the next three decades, to eighty-eight million in 2050.Footnote ⁷³ And as the elderly population grows, Medicare spending will continue to increase.Footnote ⁷⁴ Medicaid has also grown over the years and now covers more patients than does Medicare.Footnote ⁷⁵ As of 2020, Medicaid covered 75.3 million people—around one in every five Americans.Footnote ⁷⁶ As Medicaid has expanded to provide services to more patients, its share of the federal budget has increased substantially.Footnote ⁷⁷ In 1985, Medicaid covered twenty million people, and the program consumed 2.4 percent of the federal budget.Footnote ⁷⁸ In 2020, the program consumed nine percent of the budget.Footnote ⁷⁹

Systemic diet-related health issues contribute directly to these high costs.Footnote ⁸⁰ The United States spends more than one trillion dollars annually on direct medical expenses generated by diet-related health conditions.Footnote ⁸¹ For comparison, direct spending on diet-related health conditions in the U.S. is comparable to the entire GDP of Indonesia or the Netherlands.Footnote ⁸² Designing effective systems to improve health and well-being will reduce the burden that diet-related health conditions place upon our health system.Footnote ⁸³

The role of diet in preventive medicine

Diet is an essential component of preventive medicine. The root of many health challenges lies in SDOHs.Footnote ⁸⁴ These determinants are often present and detectable long before a patient is diagnosed with a long-term chronic disease.Footnote ⁸⁵ By interfering with these social and environmental risk factors, governments can reduce poor health outcomes and staunch the development of preventable diseases.Footnote ⁸⁶ Improving Americans’ diets would save lives while reducing medical costs and increasing productivity,Footnote ⁸⁷ and one way to catalyze diet improvement is to institute increases in fruit and vegetable consumption.

Fruit and vegetable consumption has been shown to significantly improve health and decrease the risk of chronic disease.Footnote ⁸⁸ Consuming fruit and vegetables lowers the risk of chronic diseases such as diabetes, cardiovascular disease, obesity, and some cancers.Footnote ⁸⁹ (Approximately half of all adults in the United States have at least one diet-related chronic disease, such as cardiovascular disease, type 2 diabetes, or obesity.Footnote ⁹⁰) Additionally, fruit and vegetables lower the risk of mortality from preexisting cardiovascular disease.Footnote ⁹¹ In the United States, more than a fifth of adult deaths caused by coronary heart disease are associated with low fruit or vegetable intake.Footnote ⁹²

Consuming fruit and vegetables also dramatically impacts the health of specific patient populations. Prediabetic people who consume fruit and vegetables generally have lower A1C levels, a predictor of diabetes.Footnote ⁹³ Pregnant women who consume fruit and vegetables are associated with positive birth outcomes,Footnote ⁹⁴ whereas poor diets during pregnancy have been linked to increased risk of birth complications including preterm birth, diabetes, hypertension, and increased gestational weight gain.Footnote ⁹⁵ Elderly patients who consume just one serving of leafy green vegetables per day experience slower declines in brain function.Footnote ⁹⁶ Fruit and vegetable consumption is also linked to decreased depression.Footnote ⁹⁷

In general, however, Americans do not consume adequate quantities of fruit and vegetables.Footnote ⁹⁸ Only one out of every ten American adults consumes the recommended amount of fruit and vegetables daily.Footnote ⁹⁹ And there exist considerable disparities in fruit and vegetable consumption across groups of varying socio-economic status, race, ethnicity, and geography.Footnote ¹⁰⁰ Nutritional disparities result in poorer health outcomes in disadvantaged communities than in wealthy ones.Footnote ¹⁰¹ People who struggle with food security, as do many MedicareFootnote ¹⁰² and MedicaidFootnote ¹⁰³ patients, are less likely to consume the recommended portions than the average American.Footnote ¹⁰⁴ Hispanic and Black participants in Medicaid have even higher rates of food insecurity than average.Footnote ¹⁰⁵ Likewise, Hispanic and Black Medicare beneficiaries have high rates of food insecurity.Footnote ¹⁰⁶ (Food insecurity is significantly associated with every major chronic disease: hypertension, stroke, cancer, asthma, CHD, hepatitis, diabetes, arthritis, kidney disease, and chronic obstructive pulmonary disease.Footnote ¹⁰⁷) And low-income individuals are the least likely to meet guidelines for daily servings of fruit and vegetables.Footnote ¹⁰⁸

Other groups suffering from nutritional disparity include patients living in rural environments, who have higher risk of diet-related diseases such as diabetes, hypertension, and asthma.Footnote ¹⁰⁹ Elderly people are also especially at risk for poor diets and food insecurity;Footnote ¹¹⁰ food insecurity increases the health care costs of older adults by an average of eleven percent.Footnote ¹¹¹ Finally, children are not immune from nutritional disparity, and are in fact especially vulnerable to it; one out of every ten children between the ages of two and seventeen in the United States do not consume any fruits or vegetables daily.Footnote ¹¹² The Council on Community Pediatrics has shown that poverty and food insecurity hurt self-regulation and executive function and cause toxic stress.Footnote ¹¹³

Diets absent of fruit and vegetables are linked with negative health consequences because of the nutritional deficiencies resulting from that absence, as well as the deficiencies affirmatively generated by foods consumed in the stead of fruits and vegetables. People who cannot afford fruit and vegetables often increase consumption of foods that are energy-dense and nutrient-deficient.Footnote ¹¹⁴ Consuming nutrient-deficient foods can, in turn, generate further health problems.

Indeed, cost—rather than taste—is cited as a primary barrier to adequate fruit and vegetable consumption;Footnote ¹¹⁵ very few people do not like fruit or vegetables as a general rule.Footnote ¹¹⁶ Many low-income individuals simply have trouble obtaining and consuming fresh fruit and vegetables.Footnote ¹¹⁷ More than thirty-seven million people in the U.S. live in food-insecure households.Footnote ¹¹⁸ Fresh produce is expensive for economically disadvantaged families who often opt instead for inexpensive processed foods.Footnote ¹¹⁹ A 2005 study showed that low-income families have to allocate an estimated forty-three to seventy percent of their food budget to fruit and vegetables to meet dietary guidelines.Footnote ¹²⁰ Other complex factors inhibiting access to fruits and vegetables include education, motivation, incentives, nutritional knowledge, and cooking skills.Footnote ¹²¹ Many people also struggle to access healthy foods because they are not as easily available in some communities.Footnote ¹²²

To address these diet-related issues and the health problems they precipitate, Medicare, Medicaid, and CHIP should curtail the barriers that prevent people from purchasing and consuming fruit and vegetables. Any policy proposals should focus on empowering individuals and should realign government programs to the actual needs of the American people. For next steps, the federal government can look to the ways in which governments, nonprofits, and researchers attempt to improve diets.

Food taxes

In recent years, many countries have established taxes on sugary beverages, but only a few have taxed or subsidized other food products.Footnote ¹²⁶ In theory, taxes could disincentivize the purchase of unhealthy foods such as sugary beverages or junk food.Footnote ¹²⁷ But junk food taxes are often met with political pushback.Footnote ¹²⁸ For example, in 2011, Denmark began taxing saturated fats; the country swiftly repealed this tax in 2013.Footnote ¹²⁹ Food taxes also face formidable political challenges from interest groups.Footnote ¹³⁰ In Mexico, Brazil, Fiji, Chile, Canada, Spain, and England, conflicts of interest consistently undermine policy attempts.Footnote ¹³¹

Some academics and government leaders have suggested a combination of taxes and subsidies. One New Zealand model study compared various taxes and subsidies and found that a combined fruit and vegetable subsidy and sugar tax would most greatly decrease health care costs.Footnote ¹³² Such a policy might optimize health, but it would likely run into the same political opposition as food taxes.

Food taxes in the United States

Food taxes are a poor fit for the United States, a nation whose national identity is premised upon the spirit of liberty and choice. And economists view choice as a fundamental market principle.Footnote ¹³³ For illustration of the likely inefficacy of junk food taxation, consider Michael Bloomberg’s 2012 attempt to ban the sale of sodas larger than sixteen ounces in specific locations across New York City.Footnote ¹³⁴ His proposal faced backlash from across the political spectrum. Conservatives lambasted Bloomberg as a “nanny” while liberal comedian Jon Stewart declared “No! … I love this idea you have of banning sodas larger than sixteen ounces. It combines the draconian government overreach people love with the probable lack of results they expect.”Footnote ¹³⁵

The United States should adopt health food subsidies instead of junk food taxes. Food taxes are a poor policy fit for the United States,Footnote ¹³⁶ but governments can still effort to design policies that respect individuals and help them to make healthy lifestyle choices. In fact, governments cannot remain neutral in preference formation.Footnote ¹³⁷ Significant challenges such as poverty shape choices and preferences.Footnote ¹³⁸ Impoverished people then make “market choices” that are direct products of deprivation.Footnote ¹³⁹ These choices are also shaped by decades of governmental policy. For decades, the United States government has stimulated the production and distribution of starchy staple commodities and shelf-stable processed foods.Footnote ¹⁴⁰ Government policies helped create the current diet-related health crisis; they should now incentivize the consumption of healthy foods. Healthy food subsidies afford people access to quality nutrition.Footnote ¹⁴¹ In diverse communities across the United States, health care-linked produce subsidies have empowered people to make positive health choices. These produce prescription subsidies have the potential to make a broader impact.

Produce prescriptions in the United States: proven to improve nutrition

In the United States, nonprofits, governments, and health care providers have created partnerships and designed programs that successfully improve nutrition and health outcomes. These programs allow clinical health providers to prescribe subsidized fresh fruit and vegetables to patients. Health care providers prescribe produce to address food insecurityFootnote ¹⁴² as well as a range of diet-affected health conditions including prediabetes, diabetes, and hypertension.Footnote ¹⁴³ These programs are designed to link nutrition and health care and are commonly referred to as “produce prescriptions,” “veggie scripts,” or “veggie Rx.”Footnote ¹⁴⁴ Numerous studies have demonstrated that produce prescriptions improve diets and health care outcomes.Footnote ¹⁴⁵

Produce prescriptions are successful because they address two barriers to fruit and vegetable consumption. First, they make healthy produce more affordable.Footnote ¹⁴⁶ Second, they educate and motivate people to make lasting dietary changes. Affordability and nutrition-related education have been shown to increase the consumption of fruit and vegetables.Footnote ¹⁴⁷ Produce prescriptions allow people to afford healthy diets. Subsidies allow people to make dietary changes irrespective of income level. Many highly nutritious fruits and vegetables, such as berries, are expensive; produce prescriptions empower patients to purchase otherwise-unaffordable nutritious and tasty foods such as raspberries, grapes, and blueberries.Footnote ¹⁴⁸ Additionally, health care providers can use produce prescriptions to educate and motivate patients while empowering them to change their diets.Footnote ¹⁴⁹ Before providing a produce prescription, health care providers educate patients about the importance of fruit and vegetable consumption.Footnote ¹⁵⁰ Research shows that advice from medical professionals helps motivate patients to make and sustain behavioral change.Footnote ¹⁵¹ Lasting dietary change can be difficult. People are more likely to follow the advice of individuals who are trustworthy, confident, and have special expertise.Footnote ¹⁵² Americans continue to hold health care providers in this type of high esteem.Footnote ¹⁵³

Health care providers have implemented many produce prescription programs across the United States; extensive research reveals the benefits of these programs.Footnote ¹⁵⁴ Nonprofit organizations, farmers’ markets, and health clinics initially developed produce prescription programs in rural, urban, and Native American communities.Footnote ¹⁵⁵ Produce prescriptions have been implemented in at least thirty-nine-states, the Navajo Nation, and the District of Columbia.Footnote ¹⁵⁶ Most produce prescription programs have been run by nonprofit organizations. While these programs have been very successful in improving community health outcomes, nonprofits generally have limited funds as they often rely on short-term private or public grants.Footnote ¹⁵⁷ As a result, nonprofits have struggled to sustain produce prescription programs long-term. Despite funding limitations, the number of produce prescription programs has substantially increased in recent years,Footnote ¹⁵⁸ although they are still only available in a limited number of communities.

Researchers have partnered with nonprofit community organizations and local health departments to study the impact of these programs.Footnote ¹⁵⁹ The resulting research reveals that these programs decrease blood pressure, reduce hemoglobin A1C levels in persons with diabetes, decrease depressive symptoms, and improve overall health.Footnote ¹⁶⁰ Additionally, these programs have been shown to decrease food insecurity and improve the relationship between patients and health care providers.Footnote ¹⁶¹

The federal government has provided support for produce prescription programs. Congress first considered supporting healthy eating programs in the 2002 Farm Bill.Footnote ¹⁶² Initially, this investment came through the Healthy Incentives Pilot (HIP) and Food Insecurity Nutrition Incentive (FINI).Footnote ¹⁶³ Now, the federal government provides funding through the Gus Schumacher Nutrition Incentive Program (GusNIP).Footnote ¹⁶⁴ In the 2018 Farm Bill, the federal government allocated $25 million towards produce prescription programs.Footnote ¹⁶⁵ The federal government has also committed to raising funding to fifty-six million dollars by 2023.Footnote ¹⁶⁶ In the 2021 American Rescue Plan Act, Congress increased produce prescription funding by $40 million.Footnote ¹⁶⁷ The federal government does not directly run produce prescription programs. Instead, the federal government funds nonprofit organizations as well as state and local agencies that implement and evaluate produce prescription programs.Footnote ¹⁶⁸ These investments, however, are limited in nature and are not designed as a permanent public policy.Footnote ¹⁶⁹

Impact on disadvantaged communities and individuals

Research indicates that including produce prescriptions in Medicare, Medicaid, and CHIP would help many of the most vulnerable members of our society.Footnote ¹⁷⁰ Much of the early research on produce prescriptions is focused on statistical health improvements,Footnote ¹⁷¹ and numerous studies conclude that produce prescription programs significantly improve health outcomes by empowering disadvantaged individuals to improve their diets.Footnote ¹⁷² These studies reveal that produce prescriptions fortify health outcomes among racial and ethnic minorities,Footnote ¹⁷³ underprivileged people in low-development rural areas,Footnote ¹⁷⁴ elderly persons,Footnote ¹⁷⁵ and children growing up in low socio-economic status families.Footnote ¹⁷⁶ While no single policy will end inequality, produce prescriptions are a step forward in solving long-standing health inequalities.Footnote ¹⁷⁷

Children also benefit significantly from produce prescription programs. Additionally, produce prescriptions have been shown to increase fruit and vegetable consumption among children.Footnote ¹⁷⁸ Produce prescriptions allow families to purchase otherwise expensive soft fruits such as berries.Footnote ¹⁷⁹ These desirable and nutritious foods are popular with children but are often too expensive for financially challenged families.Footnote ¹⁸⁰

Finally, research shows that produce prescriptions decrease blood pressure, reduce body mass index scores, and reduce hemoglobin A1c levels in individuals with diabetes.Footnote ¹⁸¹ Produce prescriptions have been associated with improvements in household food insecurity, self-reported health measures, social health, and number of medications.Footnote ¹⁸²

Personal testimonies: produce prescriptions work

Personal testimonies shared during research also illuminate the benefits of produce prescriptions.Footnote ¹⁸³ In one notable study, researchers in Cleveland, Ohio interviewed produce prescription participants to better understand the personal impact of these programs.Footnote ¹⁸⁴ The researchers interviewed African American patients with variations in age, gender, clinic, and economic position.Footnote ¹⁸⁵ Patients shared that the produce prescription program made them feel like the health care providers truly cared for them. Footnote ¹⁸⁶ One patient described that the program showed her that “there is someone out there that does care that you do better with healthier eating.”Footnote ¹⁸⁷ Patients also described how produce prescriptions improved their health and financial condition. One patient explained:

Additionally, researchers have interviewed health care providers who provide produce prescriptions to patients.Footnote ¹⁸⁹ Providers explain that produce prescription programs allow them to show that they truly care about their patients’ health.Footnote ¹⁹⁰ One pharmacist remarked that “[w]hen we do things like this, it shows a lot of effort on our part to help them, and that touches them.”Footnote ¹⁹¹ Research suggests that health care providers avoid screening for food insecurity because providers feel like they currently have little to offer food-insecure patients.Footnote ¹⁹² Produce prescriptions are a tangible and effective tool that health care professionals could use to care for food-insecure patients.

The cost-effectiveness of produce prescriptions

Including produce prescriptions in Medicare and Medicaid could save the United States billions of dollars in direct medical expensesFootnote ¹⁹³ by decreasing the burden that diet-related chronic diseases impose upon the health care system. Poor diets burden the health care system through increased hospitalizations, emergency-room visits, and higher health care costs.Footnote ¹⁹⁴ By decreasing the amount of money spent on preventable diet-related diseases, health care providers can refocus their time, energy, and resources on other formidable health challenges. And reducing avoidable burdens on the system will only become an increasingly important policy aim in the coming years and decades.

Including produce prescriptions would also decrease overall federal expenditures on treatments.Footnote ¹⁹⁵ Taxpayers are already publicly paying the cost of health care for more than one in three Americans.Footnote ¹⁹⁶ Produce prescriptions would redirect some expenditures from traditional treatment to fruit and vegetable production. As such, produce prescriptions could potentially decrease overall federal expenditures, but further research is needed to evaluate potential cost savings. Research should focus on produce prescriptions’ potential impacts on all costs, including food subsidies, administrative costs, and health care staff time, data needs, and technology infrastructure.Footnote ¹⁹⁷ Likewise, studies should estimate the benefits from all improvements to health, reduced burden on the health system from diet-related chronic diseases, and improved productivity.

A 2019 study concluded that including produce prescriptions in Medicare and Medicaid could save the United States $39.7 billion in direct health care costs over an 18.3 year lifetime.Footnote ¹⁹⁸ The study was based on the eighty-two million adults aged thirty-five to eighty who were enrolled in Medicare and Medicaid when the study was conducted.Footnote ¹⁹⁹ The study calculated the 18.3 year lifetime based on the average age—68.1—of Medicare and Medicaid participants and their expected lifespan of 18.3 years.Footnote ²⁰⁰ This study focused on type 2 diabetes and cardiovascular diseaseFootnote ²⁰¹—two preventable diseases that most substantially burden the health care system. The study modeled the impacts of a thirty-percent produce prescription discount on fruits and vegetables for Medicare and Medicaid patients.Footnote ²⁰² The thirty-percent subsidy was based on the subsidy used in the United States Department of Agriculture’s (USDA’s) Healthy Food Incentives Pilot.Footnote ²⁰³

The Healthy Food Incentives Pilot was a randomized controlled trial within the Supplemental Nutrition Assistance Program (SNAP) to incentivize fruit and vegetable consumption.Footnote ²⁰⁴ The study included formal health care, informal health care, and lost-productivity costs.Footnote ²⁰⁵ Additionally, the study evaluated the human impact through quality-adjusted life years (QALYs), which measure the disease burden on both quality and quantity of life.Footnote ²⁰⁶ The study evaluated expenses including implementation through adapting existing electronic benefits transfer systems and factored in the increased cost of setup in the initial year.Footnote ²⁰⁷ The study factored in personnel, training, monitoring, and evaluation costs.Footnote ²⁰⁸ To determine the effect of price changes on produce consumption, the researchers conducted a meta-analysis of interventional and prospective observational studies.Footnote ²⁰⁹ The researchers estimated that a thirty percent fruit and vegetable subsidy in Medicare and Medicaid would increase mean intakes of fruit by approximately 0.4 servings per day and vegetables by approximately 0.4 servings per day.Footnote ²¹⁰

The study concluded that produce prescriptions are at least as cost-effective in treating cardiovascular disease and diabetes as several existing drug treatments.Footnote ²¹¹ The study further calculated that produce prescriptions would prevent 1.93 million cardiovascular events and 350,000 cardiovascular deaths over a lifetime.Footnote ²¹² Additionally, the study found that individuals would gain 4.64 million quality-adjusted life years.Footnote ²¹³ Overall, the study found that the net cost of the program would be $68.8 billion over the 18.3 year lifetime.Footnote ²¹⁴ After five years, the probabilities that fruit and vegetable incentives would be cost effective were 0.886 overall, 0.909 for Medicare, 0.506 for Medicaid, and 0.859 for dual-eligible beneficiaries.Footnote ²¹⁵ Over the 18.3 year lifetime, the probability of fruit and vegetable incentives being cost effective was 1.00 for the overall subsidy as well as 1.00 in each of Medicare, Medicaid, and among dual-eligible beneficiaries.Footnote ²¹⁶ The researchers found that the programs were cost-effective over a lifetime in one thousand out of one thousand simulations.Footnote ²¹⁷

This study is informative, but further research is necessary. The study was strong as it used nationally representative data, included many costs, and used conservative estimates.Footnote ²¹⁸ At the same time, this study has several limitations relevant to the policy recommendations of this Article. First, this study is a microsimulation using a simulated US population rather than a study with real participants. Second, this study only measured the health impacts of produce prescriptions on diabetes and cardiovascular disease.Footnote ²¹⁹ While these are major drivers of federal health spending, many other diseases are also linked to low fruit and vegetable consumption. The researchers specifically noted that they neglected to evaluate the impact of cancer and other obesity-mediated conditions which could underestimate observed benefits.Footnote ²²⁰ Beyond these diseases, fruit and vegetable consumption impacts many health outcomes from overweightFootnote ²²¹ to brain longevity.Footnote ²²² This study also failed to include the value of other less tangible benefits such as improved mental health and stronger patient-provider relationships. Some of these benefits may be difficult to quantify, but future studies will ideally measure a broader range of health benefits.

Third, after the COVID-19 pandemic, this study is out of date. Since the pandemic, the United States has experienced extensive inflation, and food prices have risen dramatically. Prices for drugs and clinical services have also increased. As a result, the financial details of this 2019 study are not up to date. Fourth, this study does not include CHIP in its analysis. Improved diets for children can improve executive function and development in childhood which puts children on a healthy track.Footnote ²²³ Fifth, the study used a 30% subsidy. This subsidy rate may not be the ideal percentage. This percentage was based on a SNAP study rather than a study within Medicare, Medicaid, and CHIP.Footnote ²²⁴ Before implementing a national program, researchers must analyze the optimal percentage subsidy to find a number that maximizes health benefits relative to public subsidy investment.

Other studies have also suggested that improved diets could result in substantial health care savings. One 2017 meta-study found that increasing produce consumption from below 0.5 cups per day to more than 1.5 cups per day could save $1,568 per person annually in reduced costs from cardiovascular disease treatment.Footnote ²²⁵ While this study was not focused on produce prescriptions specifically, it suggests that improved diets could dramatically reduce health care costs even when looking at a single metric such as cardiovascular disease.

Another study found that subsidizing fruit and vegetable consumption by thirty percent through SNAP over a lifetime would reduce the incidence of myocardial infarction by 1.4%, type 2 diabetes by 1.7%, and stroke by 1.2%.Footnote ²²⁶ This study was not focused on produce prescriptions specifically, but the results suggest that subsidies alone, even without the additional benefits of produce prescriptions, could improve health.

Based on the existing research, it is unclear what the overall cost and health savings per enrollee would be. Nevertheless, existing research suggests that produce prescriptions could reduce health expenditures. Current research is being conducted to further determine how much money produce prescriptions could save.Footnote ²²⁷ The Centers for Medicare and Medicaid Services (CMS) should conduct additional economic research through administrative programs and pilot projects as outlined later in this Article. In conducting research, CMS should note that many health care benefits may only show up in the long-term.

Finally, implementing produce prescriptions would require significant upfront financial investment.Footnote ²²⁸ The United States government should consider nutrition a priority for national health, equity, and economic security.Footnote ²²⁹ Historically, the government has underfunded the prevention of chronic diseases.Footnote ²³⁰ These diseases dramatically decrease the health of people and greatly burden the economy.Footnote ²³¹ Federal policy should recognize the gravity of chronic-diseases and respond by implementing a produce prescription program. Although many researchers have found consistent health benefits from produce prescription programs, few researchers have studied the economic effects of a national program. Future research should consider the wide-ranging benefits of produce prescriptions including decreased incidence of chronic diet-related diseases, improved productivity, and overall improvements to health.

Ultimately, health policy—and thus health care spending—in the United States has primarily focused on treating illness, not on preventing diseases and reconciling health disparities.Footnote ²³² The United States health system does an excellent job of treating acute illnesses, but the system fails to prevent many diseases from developing.Footnote ²³³ From a financial perspective, “22.5 percent of all medical expenditures are spent on just 1 percent of the population.”Footnote ²³⁴ While combatting acute illness and reducing suffering is a noble goal, the United States should also work to prevent such chronic illnesses from developing in the first place. Although the United States has the highest per capita medical spending in the world, other countries have higher life expectancies and lower infant mortality rates.Footnote ²³⁵ Health policy should focus on improving the population’s health and life expectancy.Footnote ²³⁶ Lifestyle behaviors such as diet ultimately impact mortality rates, and are thus worthy investments.Footnote ²³⁷

Existing federal nutrition programs

Most nutrition policies focus on the high cost of food. SNAP and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) play an important role in reducing food insecurity. These programs allow a wide range of food purchases to reduce overall hunger and meet basic needs. SNAP, WIC, and other nutrition assistance programs benefit millions of Americans and reduce food insecurity, but are not alone sufficient to solve the diet-related chronic disease crisis.Footnote ²³⁸ In contrast to these programs, produce prescriptions focus on reducing the cost of fruit and vegetables to improve diet-related chronic illnesses and improve overall health outcomes. Both SNAP and WIC have small fruit and vegetable subprograms, but these subprograms are underinclusive and are only available at limited redemption locations.

States have successfully implemented incentives within the SNAP program that double the value of fruit and vegetable purchases at farmers markets.Footnote ²³⁹ For example, Oregon’s Double Up Food Bucks program doubles the value of SNAP for fruit and vegetable purchases at farmers markets and limited grocery stores in Oregon.Footnote ²⁴⁰ While these programs improve fruit and vegetable affordability for SNAP participants, they are underinclusive. Many eligible people do not sign up for SNAP due to the stigma of “food stamps.”

Alongside SNAP, the USDA currently administers WIC in partnership with states.Footnote ²⁴¹ The main WIC program only covers $11 per month of fruit and vegetables for women and $8 per month for children.Footnote ²⁴² WIC also includes a subprogram, the Farmers Market Nutrition Program (FMNP).Footnote ²⁴³ This program allows eligible WIC participants to receive fresh, locally grown fruit and vegetables directly from farmers markets.Footnote ²⁴⁴ FMNP has been successful, but is ultimately underinclusive. WIC has very limited eligibility and covers a tiny fraction of the U.S. population; FMNP applies only to a small portion of the people that could benefit from fresh produce.Footnote ²⁴⁵ Additionally, redeeming produce coupons at farmers markets is not practical for some individuals;Footnote ²⁴⁶ farmers markets are often seasonal and are not available in many communities.Footnote ²⁴⁷ FMNP’s benefits also suffer from severe limitation: FMNP benefits are capped at an average of $26 annually across the states,Footnote ²⁴⁸ and are $30 annually in the states with the most generous programs.Footnote ²⁴⁹ Finally, unlike federal health care programs, WIC is often seen exclusively as a welfare program, and some needy individuals may avoid signing up for WIC due to welfare stigmatization.Footnote ²⁵⁰

SNAP’s and WIC’s subprograms have been linked to greater food security and higher fruit and vegetable intake, but they are far from perfect: they often have limited reach and offer limited redemption locations. Additionally, these subprograms are focused on cost, and do not incorporate education or motivation as produce prescriptions under Medicare, Medicaid, and CHIP could.

Other potential nutrition policies aimed at enabling and incentivizing fruit and vegetable consumption

Some nutrition advocates argue that the government should increase labeling on unhealthy foods such as breakfast cereals and sodas.Footnote ²⁵¹ While fortifying labeling practices could help educate consumers, it would fail to address cost barriers to purchasing healthier options. Additionally, changes in labeling practices are unlikely to gain popular support and would face significant lobbying pushback from agricultural industries.

Other researchers propose that the federal government further subsidize fruit and vegetable production. Less than one percent of farm subsidies go to fruit and vegetable production.Footnote ²⁵² More heavily subsidized fruit and vegetable production means lower fruit and vegetable prices. Subsidizing produce production, however, is a less targeted approach than produce prescription programs. Produce prescriptions and fruit and vegetable subsidies in SNAP and WIC provide more targeted nutritional benefits to people who most need them. (Of course, targeted programs can be underinclusive: people can lose Medicaid, SNAP, or WIC when their income increases.)

Increasing collaboration between federal health care programs and food programs such as WIC and SNAP might also serve to address deficient produce consumption.Footnote ²⁵³ Medicaid and CHIP patients could benefit from WIC and SNAP benefits. Currently, only twenty-six state WIC agencies periodically meet with state Medicaid and/or SNAP agencies.Footnote ²⁵⁴ Additionally, twenty-seven state WIC agencies have written agreements with Medicaid or SNAP, and twenty-two WIC agencies share data with Medicaid or SNAP.Footnote ²⁵⁵ These numbers demonstrate that federal health programs and federal food programs are siloed and insulated from one another. Although participants in Medicaid and CHIP should typically be eligible for federal food program benefits, many do not enroll.Footnote ²⁵⁶ For example, eighty-seven percent of children under the age of five who received health care from federal programs were eligible for WIC, but thirty-nine percent of these children did not participate in WIC.Footnote ²⁵⁷ States could improve enrollment in WIC and SNAP by improving lateral enrollment processes. For example, states could automatically sign-up eligible Medicaid and CHIP patients for SNAP or WIC. An opt-out process would likely have higher rates of participation than an opt-in process;Footnote ²⁵⁸ in turn, disadvantaged individuals’ purchasing power would increase, thereby improving access to healthy food.

There are limitations to the potential efficacy of cross-program collaboration, however. For example, these changes might not reach all Medicare recipients due to income ineligibility, so could potentially be underinclusive compared to the institution of produce prescriptions in Medicare, Medicaid, and CHIP. Additionally, while increasing overlap between federal health care and federal food programs would expand access to healthy food, it would not be targeted at fruit and vegetables and diet specifically. In contrast, CMS-based produce prescriptions would focus directly on improving fruit and vegetable consumption to prevent diet-related chronic diseases.

Increasing interactions between federal health care programs would not be a replacement for produce prescriptions, but doing so could work well in conjunction with produce prescriptions. If produce prescriptions were designed as a discount rather than a cash benefit, the discount could be applied to SNAP purchases. Ideally, state and local governments should consider and implement multiple nutrition policies to improve health care outcomes. The government should also study what works in current programs to design effective produce prescription programs. For example, WIC already has a successful implementation design that allows participants to only receive specific subsidized food items at a wide range of distribution locations.Footnote ²⁵⁹

Why produce prescriptions fit a unique need

While the above policies could help address the cost of fruit and vegetables, they do not connect directly to health care. In contrast, produce prescriptions help motivate and educate patients to make dietary change—an extraordinarily difficult endeavor for most Americans. Produce prescriptions link dietary change to the health care issues that individuals face routinely by encouraging healthy food choices, reducing price barriers, and motivating lasting change.

Ultimately, produce prescriptions would not replace SNAP, WIC, or other basic needs services. They would be distinct and complementary. The primary goal of SNAP and WIC is to meet basic needs: preventing hunger and improving the food purchasing power of low-income individuals. In contrast, produce prescriptions in federal health programs would primarily center upon the goal of improving diets through increased fruit and vegetable consumption. This, in turn, would reduce the incidence and severity of diet-related chronic diseases. And, as discussed in Sections VI.A and VI.B, supra, many people who need help with their nutrition are hesitant to seek help from SNAP or WIC due to the stigma attached to welfare. Produce prescriptions would carry a different identity and would, ideally, be administered through programs that are viewed not as welfare programs but as health insurance programs instead.

Policy design of produce prescriptions

Produce prescription programs should be designed to best meet the actual needs of Medicare, Medicaid, and CHIP patients. Produce prescription studies have consistently shown the importance of maximizing choice for consumers. As such, governments should design programs to empower individuals to make their own healthy food choices, rather than restrict their capacity to choose. And produce prescriptions should be easy to obtain, understand, and use.

Using produce prescriptions to enhance produce accessibility in food deserts

Across the United States, many low-income communities have limited access to affordable healthy food.Footnote ³²³ These communities are classified as “food deserts.”Footnote ³²⁴ Food deserts increase food disparities and cause poor health outcomes.Footnote ³²⁵ Many economically challenged, highly urban, and rural communities lack an adequate number of accessible grocery stores—and thus lack the fresh, healthy food that most grocery stores stock. In rural communities, for example, both the lack of fresh fruit and vegetables and the high cost of produce contribute to food deserts.Footnote ³²⁶ The presence and quality of grocery stores and other retail food markets in a given community greatly impact how and what members of that community purchase and ultimately consume.Footnote ³²⁷

Crucially, produce prescriptions could improve access to fruit and vegetables in food deserts. First, produce prescriptions decrease the cost of fresh produce.Footnote ³²⁸ In many food deserts, fresh produce is available but is too costly for low-income individuals to afford. Food prices are often higher in low-income neighborhoods than in high-income neighborhoods.Footnote ³²⁹ Low-income areas tend to have fewer markets and these markets tend to be smaller.Footnote ³³⁰ Smaller stores generally have higher prices.Footnote ³³¹ As a result, low-income areas tend to suffer from high food prices.Footnote ³³² Produce prescriptions can destabilize this cost barrier by subsidizing fruit and vegetables. Second, governments can reward community engagement.Footnote ³³³ Governments could use produce prescription programs to incentivize businesses to offer healthy foods in food deserts. For example, governments could provide additional subsidies to food retailers in food deserts. Footnote ³³⁴ Governments could tie these subsidies to how many produce prescriptions are redeemed at a market.Footnote ³³⁵ Third, produce prescriptions increase demand for fresh produce in food deserts. Increased demand in these areas can stimulate local businesses to offer more produce. If produce incentives increase sales and revenue for local businesses, those stores may in turn fund further incentives.Footnote ³³⁶ Fourth, local governments, health care organizations, and nonprofits could partner with farmers markets to offer additional produce pickup locations in communities.

Produce prescriptions in Medicare

Including produce prescriptions in Medicare has the potential to drastically improve health outcomes. Medicare is administered by the federal government and currently serves 62.8 million Americans.Footnote ³³⁷ Many Medicare patients have diet-related chronic diseases: fifty-seven percent of fee-for-service beneficiaries have hypertension and twenty-seven percent have diabetes.Footnote ³³⁸ The multiple ways to implement produce prescriptions into Medicare’s structure are discussed below.

Produce prescriptions in Medicaid

Medicaid should also cover produce prescriptions. Medicaid is a federal program administered primarily by the states. Medicaid currently serves 76.5 million Americans.Footnote ³⁷⁷ Twenty-three percent of Medicaid participants are food insecure.Footnote ³⁷⁸ Because Medicaid is administered as a partnership between federal and state governments, there are opportunities for produce prescription implementation at both the federal and state levels.Footnote ³⁷⁹

States flexibly run Medicaid within broad federal statutory and administrative guidelines. While CMS provides states with a framework for Medicaid, states also have flexibility in how they administer these programs. For example, more than a decade after the Affordable Care Act, twelve states have still not expanded Medicaid.Footnote ³⁸⁰

Produce prescriptions in CHIP

CHIP provides insurance for 6.87 million childrenFootnote ⁴⁰⁵ whose families cannot afford private insuranceFootnote ⁴⁰⁶ but earn too much money to qualify for Medicaid.Footnote ⁴⁰⁷ CHIP receives both state funding and federal block grant funding but is administered by the statesFootnote ⁴⁰⁸ and is authorized within the Social Security Act under Title XXI.Footnote ⁴⁰⁹ Each state provides a State Children’s Health Insurance Program, and the federal government provides block-grant funding directly to the states. State CHIP plans must meet either Medicaid requirements (Title XIX), CHIP coverage requirements (Section 2103), or both.Footnote ⁴¹⁰

CHIP is run with wide state discretion within federal guidelines.Footnote ⁴¹¹ The federal government provides various basic requirements. For example, state children’s health insurance plans must cover low-income children, and state plans cannot deny children based on pre-existing conditions.Footnote ⁴¹² State CHIP programs are funded by annual block grant allotments from CMS.Footnote ⁴¹³ In order to receive their federal allotment, states are required to provide matching funds.Footnote ⁴¹⁴ States run CHIP programs under various administrative options. For example, states can run CHIP under Section 2103, as an expansion of Medicaid, or as a combination of both programs.Footnote ⁴¹⁵ The federal government requires that state CHIP programs include comprehensive coverage including routine check-ups, dental and vision care, and prescriptions.Footnote ⁴¹⁶ States are able to provide additional services, as well.Footnote ⁴¹⁷

While the federal government requires certain baseline benefits, individual states have a significant amount of leeway in adding additional benefits. Because the federal government provides a significant portion of CHIP’s funding, the federal government may have a greater incentive to develop comprehensive produce prescription programs within CHIP and could do so via codification or administrative policy.

Many CHIP programs are run in partnership with Medicaid. CHIP incorporates benefits from the same statute as Medicaid (Title XIX).Footnote ⁴¹⁸ CHIP also incorporates benefits under section 2103 of Title XXI.Footnote ⁴¹⁹ Under Title XXI section 2105, CHIP provides payments to states for “child health assistance.”Footnote ⁴²⁰ In Section 2110, the CHIP statute provides a definition of child health assistance.Footnote ⁴²¹ This statute could be interpreted broadly to already allow for produce prescriptions, but for clarity, specific codification would be a better option. Congress should amend both Title XIX at 42 U.S.C. § 1395x(s)(2) and Title XXI at 42 U.S.C. § 1397jj(a) to include produce prescriptions in the lists of services.

Under Title XXI Section 2110, “child health assistance” is defined.Footnote ⁴²² The definition includes numerous services. Although produce prescriptions are not listed as an option, they could fit under subsection 24, which includes “any other … preventive … therapeutic, or rehabilitative services … if recognized by State law and only if the service is (A) prescribed by or furnished by a physician or other licensed or registered practitioner within the scope of practice as defined by State law …”Footnote ⁴²³ Additionally, CHIP can cover “any other health care services or items specified by the Secretary and not excluded under this section.”Footnote ⁴²⁴ CMS could interpret produce prescriptions within the definition of “child health assistance” and could provide guidance to states to promote produce prescriptions in CHIP.

In 2021, CMS issued a study about how state CHIP programs can address social determinants of health.Footnote ⁴²⁵ This research study gave states guidance about how they can expand coverage under current law to include housing-related services and supports, non-medical transportation, educational services, and employment supports.Footnote ⁴²⁶ This CMS report provided guidance about home-delivered meals, but did not provide guidance about produce prescriptions.Footnote ⁴²⁷ This document does not make clear whether CMS considers meals as part of a separate legal category from other nutritional interventions such as produce prescriptions.Footnote ⁴²⁸ Moving forward, CMS could interpret “child health assistance” broadly, approve state CHIP innovations, and provide guidance and encouragement for state programs to implement produce prescriptions.

As with Medicaid, HHS is authorized to approve experimental, pilot, or demonstration projects within CHIP.Footnote ⁴²⁹ These could be authorized through 1115 Section waivers.Footnote ⁴³⁰ Additionally, CHIP authorizes states to improve the health of low-income children through the Health Services Initiative (HSI).Footnote ⁴³¹ This program allows health services such as emergency food relief for families.Footnote ⁴³² States could potentially implement produce prescriptions through CHIP HSIs.

State and federal administration

At the federal level, there are multiple ways to administer a national produce prescription program. The federal government could administer a national produce prescription card through electronic benefits transfers. A federal national produce prescription program could coordinate with federal Medicare and state and local Medicaid and CHIP agencies to provide benefits. Implementation by the federal government would maximize uniformity and might thus be the simplest approach.

Alternatively, all produce prescriptions could be developed on a state level. State-by-state programs would be more flexible and would potentially allow for more public participation and community centered designs. States could model produce prescription electronic benefits and administration on either local SNAP or WIC programs. WIC programs are already designed to cover only certain foods, so states could copy and adapt rules from existing WIC programs.Footnote ⁴³⁸ State-run produce prescriptions would allow states to act as laboratories of democratic administration, thereby increasing creative potential. While state programs would be more flexible, they may not maintain uniform quality across all states. Congress or CMS could provide guidelines and minimum requirements to make sure that all produce prescriptions meet a nationwide standard. Finally, produce prescriptions could be run at the federal level for Medicare and at the state level for Medicaid and CHIP. This may potentially be the least efficient route.

Under any of these options, agencies would need to carefully safeguard patient privacy information to comply with HIPPA. Federal agencies have already developed processes for securely sharing health information. For example, WIC, SNAP, and Medicaid already share data in ways that protects patient privacy.Footnote ⁴³⁹ No matter how produce prescriptions are ultimately organized, though, effective produce prescriptions would most likely benefit from cross-agency collaboration.

Flexibility, public participation, and community-centered designs

Produce prescription designs should be flexible and amenable to local adaptation.Footnote ⁴⁴⁰ Because Medicaid and CHIP are administered at the state level, these programs would provide many opportunities for local adaptation. Human knowledge is widely dispersed among diverse individuals in the public.Footnote ⁴⁴¹ No single public leader or government official will possess complete knowledge of every community.Footnote ⁴⁴² So in designing a produce prescription program, the government should engage with patients, clinics, and retailers to establish an effective and efficient program.Footnote ⁴⁴³ The federal government can use several approaches to design programs that directly benefit diverse communities. First, CMS can give state and local governments the flexibility to improve produce prescription programs. Second, CMS should aim to have inclusive participatory bureaucracy. The government benefits from diverse experiences when the public is given a voice in bureaucratic planning.Footnote ⁴⁴⁴ Finally, governments should incentivize innovative partnerships between nonprofits, health care organizations, and grocery stores.

Communities can participate in produce prescription programs in many ways. Local agencies, nonprofits, and businesses could partner to provide culturally appropriate meal plans, recipes, and cooking classes.Footnote ⁴⁴⁵ Across the nation, many nonprofits are already fighting food insecurity through educational cooking and meal plan classes.Footnote ⁴⁴⁶ Local partnerships could allow for culturally appropriate educational classes and could foster community. These organizations could expand their impact if more people are motivated to eat more fruit and vegetables.

Political considerations and implications

Produce prescriptions have the potential to appeal to people across the political spectrum, given the social implications of this policy proposal or the impact that this proposal could have on government health care finances. Some may be particularly interested in how produce prescriptions in Medicare and Medicaid could improve the lives of at-risk groups such as historically disadvantaged racial and ethnic minorities. Others may be interested in how this policy could increase fiscal responsibility and would reduce burdens on our public health care system. Federal produce prescriptions aim to improve the health of patients who currently receive federal health care. The number of eligible Medicare patients is set to greatly increase in the coming decades.Footnote ⁴⁴⁷ Both Medicare and Medicaid face challenging financial futures.Footnote ⁴⁴⁸ The Medicare Trustees estimate that the Health Insurance Trust Fund will run out of reserves by 2029.Footnote ⁴⁴⁹ And produce prescription programs could potentially reduce the financial burden imposed by diet-related chronic diseases on the health care system.Footnote ⁴⁵⁰

Still others may be interested in how produce prescriptions relate to individual choice. Produce prescriptions would empower public health care patients to treat diet-related conditions like pre-diabetes with dietary change. Current policy limits patient choices to drugs and medical treatment. Finally, some may support produce prescriptions as a means of increasing funding of specialty crops and support agricultural communities. Produce prescriptions could shift public finances from pharmaceutical companies to rural farming communities throughout the U.S. Congressional support for food as medicine has reflected the bipartisan appeal of improving American diets. For example, the House Hunger Caucus includes a bipartisan Food as Medicine Working Group.Footnote ⁴⁵¹ Other preventive medicine proposals within Medicare have also gained bipartisan support.Footnote ⁴⁵² The 2018 Farm Bill included $25 million dollars to implement and study produce prescription programs.Footnote ⁴⁵³ The Farm Bill was passed on a bipartisan basis in a Republican-controlled House and Senate and signed by President Trump. More recently, with support of President Biden, a Democratic-controlled House and Senate passed $40 million in funding for produce prescriptions through the American Rescue Plan Act.Footnote ⁴⁵⁴

Expanding Medicare and Medicaid to cover produce prescriptions could also face opposition from competing interests and legislative priorities.Footnote ⁴⁵⁵ Some corporate and political groups may fear that increased produce consumption would decrease consumption of highly processed snack foods.Footnote ⁴⁵⁶ Increased demand could also increase the cost of produce if the supply does not increase as well.

Limitations of current research

Many studies have shown that produce prescriptions could result in a wide range of benefits. However, these studies lack uniform metrics, have some inconsistent results, and include differing variables. Past research designs have had little consistency and are hard to compare.Footnote ⁴⁵⁷ Additionally, these studies have had very different study designs.Footnote ⁴⁵⁸ While such diverse research has demonstrated that produce prescriptions could benefit a wide range of individuals and communities, the lack of consistent research design makes it more challenging to precisely quantify potential financial outlays and savings. Before implementing a national produce prescription program, the federal government could consider smaller scale programs outlined earlier in this article.

Future studies should use uniform models and metrics to design an effective program.Footnote ⁴⁵⁹ Researchers should analyze ideals for dosage, prescription length, and target health conditions.Footnote ⁴⁶⁰ Additionally, future researchers should study the economic impacts of produce prescriptions.Footnote ⁴⁶¹ Congress could consider a CBO study before scaling up produce prescriptions in Medicare, Medicaid, and CHIP.

State-by-state proposals independent of federal action

State and local governments can also continue to expand produce prescription programs. While state-level expansion offers opportunities, state governments have less financial incentive to reduce Medicare costs.Footnote ⁴⁶² Because Medicare is funded by the federal government, potential cost savings from reduced chronic diseases among these patients would most directly affect the federal budget. Medicaid is jointly funded by the federal and state governments. Thus, states have a potential financial incentive to offer produce prescriptions for Medicaid patients. Without federal waivers, states cannot spend federal Medicaid money on produce prescriptions. While waiting for federal action, state and local governments should continue to partner with nonprofit and health care organizations to offer produce prescriptions.

Next steps for implementing a produce prescription program

The federal government could start with large pilot projects that target Medicare and Medicaid populations.Footnote ⁴⁶³ CMS could cover produce prescriptions as part of a demonstration model.Footnote ⁴⁶⁴ CMS could also issue waivers for states to test produce prescriptions. CMS and HHS should provide guidance and technical assistance to help states implement produce prescriptions.Footnote ⁴⁶⁵ These agencies should measure new programs carefully using standardized metrics to establish the data necessary for an eventual scaled-up national program.

In addition to including produce prescriptions in Medicare, Medicaid, and CHIP, Congress should also offer produce prescriptions through the Veterans Health Administration.Footnote ⁴⁶⁶ This paper focused on Medicare, Medicaid, and CHIP because these programs are heavily connected. Food insecurity is also a major issue among veterans.Footnote ⁴⁶⁷ Produce prescriptions could improve the diets of veteransFootnote ⁴⁶⁸ and potentially decrease financial pressures on the Veterans Health Administration. The federal government could run initial pilot programs within Medicare, Medicaid, CHIP, or the Veterans Health Administration. After further data is gathered, the government could scale up produce prescriptions within all these federal programs.

Congress could also consider expanding funding and research for produce prescriptions through the 2023 Farm Bill. Ideally, produce prescription should principally be a federal health, rather than agricultural policy. Although CMS would be a better agency for produce prescriptions than the USDA, funding through the Farm Bill could lay the foundation for a larger future program.

After sufficient research exists for a national program, Congress should consider amending the Social Security Act to include produce prescriptions in Medicare and Medicaid. While codification in the Social Security Act would be the best approach for long-term produce prescriptions, this method would also be the most politically challenging. Smaller pilot projects could produce the evidence needed to support codifying produce prescriptions in the Social Security Act. Amending the Social Security Act would allow produce prescriptions to be included in the baseline benefits of these programs.Footnote ⁴⁶⁹

Indirect benefits of produce prescriptions

Local and regional farm economies stand to benefit significantly from the inclusion of federally funded produce prescriptions within Medicare, Medicaid, and CHIP.Footnote ⁴⁷⁰ If produce prescriptions are redeemed at farmers markets or through CSAs, local farm economies could benefit even more substantially.Footnote ⁴⁷¹ Allowing the application of produce prescriptions at farmers markets would incentivize consumption of healthy locally grown food, and would also stimulate local economies by incentivizing local farms to put their items up for sale at the markets.Footnote ⁴⁷²

A national produce prescription policy would also emphasize to the American public that diet has a strong, direct impact on overall health outcomes. Americans often view food and medicine separately, but what we eat daily has an extraordinary impact on health and longevity.Footnote ⁴⁷³ Including produce prescriptions in Medicare and Medicaid would further illuminate to patients the inextricable link between diet and medicine. A national produce prescription program would help to answer the “resounding call within the public health and medical fields that our current health system does not do enough to prevent disease and promote overall well-being.”Footnote ⁴⁷⁴

The risks, limitations, and disadvantages of produce prescriptions

The institution of a national produce prescription program would not be without its risks and limitations. For example, some patients simply do not follow their prescriptions, a pattern that threatens the efficacy of any prescription-based program. Research identifies several common factors that impact whether or not a patient follows their prescription.Footnote ⁴⁷⁵ These include treatment complexity, monetary costs, the presence of psychological problems, and poor provider-patient relationships.Footnote ⁴⁷⁶ Patients without primary health providers may also be less likely to adhere to prescriptions and follow health advice,Footnote ⁴⁷⁷ and twenty-three percent of Americans lack a primary health care provider (with disparities apparent along racial and ethnic, sex, educational, and income lines).Footnote ⁴⁷⁸

Additionally, while produce prescriptions have the potential to fortify children’s health, successful implementation would require parental involvement.Footnote ⁴⁷⁹ One produce prescription program directed at Indigenous Australian children did not result in significant health improvements,Footnote ⁴⁸⁰ perhaps because the targeted children had major existing nutritional challenges and likely had less control over food preparation.Footnote ⁴⁸¹ As such, governments and partner organizations should design programs to train and educate parents unfamiliar with fruit and vegetable preparation. One program implemented in the Navajo Nation provided prescription fruit and vegetables as well as monthly health coaching to parents for six months.Footnote ⁴⁸² This program improved the fruit and vegetable consumption of young children and improved their overall health.Footnote ⁴⁸³

Patients could also lose or misplace produce prescriptions.Footnote ⁴⁸⁴ Governments should design produce prescription programs that minimize these risks. For example, patients may be less likely to lose, misplace, or destroy electronic benefit transfer cards than paper prescriptions. Finally, some patients do not regularly visit physicians, which would render produce prescriptions—and other prescriptions—difficult to obtain.Footnote ⁴⁸⁵ CMS can address this challenge by allowing a wide range of health care professionals such as pharmacists and nutritionists to write produce prescriptions. Ultimately, like all health policies, a national produce prescription program policy would inevitably fail to reach some individuals. But the health care system should continue to strive to improve patient contact with the most vulnerable individuals in our country. Produce prescriptions might even serve to build trust between physicians and patients by providing patients with an alternative, affordable route to improving their health.

An additional concern about the efficacy and wisdom of implementing a national produce prescription program is that doing so could increase grocery prices. Produce prescriptions would increase demand for fruit and vegetables, so unless this policy change is accompanied by an increase in fruit and vegetable supply, this could result in higher fruit and vegetable prices for other consumers. On the other hand, increased demand for produce, particularly in food deserts, could potentially lead to more efficient supply chains and lower prices in some disadvantaged communities.

Finally, the health care system in the United States is already a burdened one; is it really the best vehicle through which to address SDOHs? Addressing food insecurity through the health system may not be the most efficient route by which to do so. However, although the United States’ health care system is indeed overburdened, much of this burden springs directly from diet-related chronic illnesses. It might take time, but because produce prescriptions would improve overall health outcomes, they would actually serve to decrease the overall burden on the health care system. In turn, more health care resources could be reallocated away from preventable diseases.

Similarly, some health care professionals may be concerned about adding another program to their already significant workflows. To address these concerns, CMS should design a simple, efficient program that is easy to streamline into pre-existing patient care routines. Ultimately, produce prescriptions are just another treatment—much like the pharmaceutical prescriptions that doctors already write for patients—yet they do not present the same risks of overdose and addiction, and do not necessitate the need for as stringent oversight.