Month: January 2023
NYHealth Comments on the New York City Groceries to Go Program
The New York City Department of Health and Mental Hygiene invited public comments on proposed rules for a subsidized grocery program, Groceries to Go. NYHealth submitted the following comments in response:
January 13, 2023
Dear Commissioner Vasan:
The New York Health Foundation (NYHealth) appreciates the opportunity to provide comments in response to the proposed amendments to Title 24 of the Rules of the City of New York, establishing rules for a subsidized grocery program, Groceries to Go. The amended and updated program, which is now designed as a Food Is Medicine intervention, can improve health outcomes, reduce food insecurity, and decrease long-term health care costs.[1]
NYHealth is a private, independent, statewide foundation dedicated to improving the health of all New Yorkers, especially people of color and others who have been historically marginalized. The Foundation’s Healthy Food, Healthy Lives program aims to connect New Yorkers with the food they need to thrive.[2] Making it easier for health care providers to connect patients with healthy food through Food Is Medicine programs is a core strategy of this program.
The proposed amendment will provide Health + Hospitals New York City Care members and eligible program enrollees who have a diagnosis of hypertension or diabetes and are at risk of food insecurity with access to healthier food through an online marketplace of local grocery stores. The Groceries to Go program is based on growing research that shows that the right kind of diet can help prevent and manage disease, while the wrong kinds of food can contribute to disease onset and worsen health conditions.
Food Insecurity in New York
Food insecurity jeopardizes health. An increasing body of evidence shows that individuals with uncertain access to food have lower diet quality, higher rates of diet-related disease, and higher health care costs.[3],[4],[5] A 2019 study estimated that in New York State, the annual health care costs associated with food insecurity top $3.4 billion, or approximately $173 per person.[6] As the Statement and Basis and Purpose section of the proposed rule states, “Research demonstrates that US adults in households with marginal, low and very low food security are more likely to have hypertension and diabetes, two of the most common diet-related chronic diseases that disproportionately burden communities of color,[7] compared to adults in high food-secure households.”[8]
Food Is Medicine refers to a spectrum of services and health interventions that respond to the critical link between poor nutrition and chronic illness.[9] Food Is Medicine programs are often targeted to people with chronic illnesses or at risk for chronic illness, and they often use a food “prescription” written by a health care provider or plan. Food Is Medicine usually takes the form of prepared meals or food/produce boxes/groceries that are medically tailored to meet an individual patient’s needs.
In 2021, NYHealth conducted primary research to capture the lived experiences of New Yorkers who are food insecure. We released the findings of a 1,507-person statewide Survey of Food and Health, which highlights the connections between food and health and contrasts the day-to-day struggles of food-insecure and food-secure New Yorkers.[10] The report also looks at New Yorkers’ experience with and perceptions of food and nutrition programs, examines their support for expanding and improving these programs, and makes recommendations for strengthening public benefits, emergency food, and meals programs. A number of the findings, highlighted below, offer important insights for the City as it rolls out the updated Groceries to Go program. I encourage you to explore the full findings and policy recommendations, which are available on our website.
Food Insecurity Is Strongly Linked with Health
Not surprisingly, NYHealth’s findings reflect the City’s cited research that food insecurity is significantly associated with chronic disease prevalence and worse health outcomes. Our findings show:
- Nearly half of all food-insecure New Yorkers rate their health as poor or fair;
- 69% report having at least one chronic illness and more than half found it difficult to get the food they need;
- 23% of chronically ill food-insecure individuals skip or delay medical care; and
- 16% delay or do not purchase prescription medication.
For chronically ill food-insecure New Yorkers, affording food is especially difficult: 72% struggle to afford the food they need. One survey respondent explained, “We don’t have enough money for food because I’ve been in and out of the hospital.”
Transportation and Cost are Major Barriers to Accessing Food
Transportation is also a major barrier for many food-insecure New Yorkers, and grocery delivery costs put online ordering out of reach for many. Two-thirds (64%) of chronically ill food-insecure individuals report that transportation is a barrier to getting the food they need, at least some of the time. One survey respondent explained, “We are both disabled and live on food stamps. We don’t drive, so getting to a food pantry is almost impossible.”
Reliance on public transportation can also restrict the food and beverages individuals purchase, as another survey respondent noted: “We do not live within a reasonable distance of any supermarkets (we do not have a car) so are often limited to purchasing whatever we can carry on the bus.”
Overwhelming Support for Delivery and Online Purchasing Options
When asked what could help them overcome barriers to get the food they need, food-insecure individuals unsurprisingly say they need more money. But they also express support for other solutions, including financial support for food delivery and improved transportation options like better access to public transit. The Groceries to Go program addresses the primary food access barriers cited by New Yorkers by providing access to healthy food for food-insecure, chronically ill New Yorkers, and should pay particular attention to the needs of New York City residents who rely on public transportation.
There is also popular support for programs that allow for purchase of groceries online. The NYHealth survey results show that more than 90% of food-insecure and 80% of food-secure New Yorkers support online grocery ordering and delivery for Supplemental Nutrition Assistance Program (SNAP) purchases. Currently, SNAP participants may use benefits online at select retailers, but traditionally, large chain stores like Amazon and Walmart have dominated the online market. NYHealth has invested in programs in the North Country of New York State that allow food-insecure individuals access to online grocery purchase and delivery from local markets. Our grantee, The Hub on the Hill, which represents local vendors, can offer important lessons learned for the Groceries to Go program.
New Yorkers Want to Talk with Their Doctors about Food Insecurity
Health care providers do not regularly screen for food insecurity, and the Groceries to Go program addresses this challenge. New Yorkers support this approach. Seventy-one percent of food-insecure individuals report that they would like to have more conversations with their doctors about the food they eat. Screening and referral processes, when implemented with fidelity, can reduce hunger and increase medical adherence.
NYHealth applauds the New York City Department of Health and Mental Hygiene for designing this innovative, evidence-based approach to addressing food insecurity among patients with chronic disease. Food-insecure New Yorkers rely upon nutrition and food programs that serve as a crucial safety net, but those programs could be improved.
These types of Food Is Medicine programs are critical and should also be paired with robust referral and enrollment services for other food and nutrition programs—including SNAP and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)—that provide a critical safety net that can help New Yorkers access the food they need to thrive. Yet many New Yorkers cannot or do not participate in these programs. Health care providers could play a critical role in connecting more food-insecure patients with these nutrition benefits.
While research is promising, health payers and health care institutions have yet to find a sustainable pathway to broadly support Food Is Medicine interventions. Groceries to Go can contribute to the evidence base for Food Is Medicine programs and inform best practices for online grocery purchase and delivery programs for food-insecure New Yorkers who have limited resources. It is imperative to understand New Yorkers’ needs and preferences and to develop policies and programs that are responsive to them. The proposed Groceries to Go program does just that.
My NYHealth colleagues and I look forward to being a resource as you work to secure and strengthen food and nutrition benefit programs and support New Yorkers’ health.
Respectfully submitted,
David Sandman, Ph.D.
President and CEO
New York Health Foundation
[1] Downer S, Clippinger E, Kummer C. Food is Medicine Research Action Plan. Published Jan. 27, 2022. https://www.aspeninstitute.org/wp-content/uploads/2022/01/Food-is-Medicine-Action-Plan-Final_012722.pdf.
[2] New York Health Foundation. Healthy Food, Healthy Lives. January 2023. https://nyhealthfoundation.org/what-we-fund/healthy-food-healthy-lives/.
[3] Morales ME, Berkowitz SA. The relationship between food insecurity, dietary patterns, and obesity. Curr Nutr Rep. 2016 Mar;5(1):54-60.
[4] Berkowitz SA, Basu S, Meigs JB, Seligman HK. Food insecurity and health care expenditures in the United States, 2011-2013. Health Serv Res. 2018;53(3):1600-1620.
[5] Gregory CA, Coleman-Jensen A. Food insecurity, chronic disease, and health among working-age adults. U.S. Department of Agriculture, Economic Research Service. July 2017. No. 235. https://www.ers.usda.gov/webdocs/publications/84467/err-235.pdf. Accessed April 2022.
[6] Berkowitz SA, Seligman HK, Meigs JB, Basu S. Food insecurity, health care utilization, and high cost: a longitudinal cohort study. Am J Manag Care. 2018;24(9):399–404.
[7] New York City Department of Health and Mental Hygiene. EpiQuery – Community Health Survey, 2017. Viewed on 11/22/2022. https://nyc.gov/health/epiquery.
[8] Gregory CA, Coleman-Jensen A. Food Insecurity, Chronic Disease, and Health Among Working-Age Adults. Agriculture USDo; 2017. July 2017. https://www.ers.usda.gov/webdocs/publications/84467/err-235.pdf?v=4007.7.
[9] https://foodismedicinema.org/food-is-medicine-interventions#:~:text=Food%20is%20Medicine%20refers%20to,between%20nutrition%20and%20chronic%20illness. January 2023.
[10] New York Health Foundation, NYHealth Survey of Food and Health. August 16, 2022. https://nyhealthfoundation.org/resource/nyhealth-survey-of-food-and-health-2022/.
State of the State: Health Hits and Misses
Earlier this week, Governor Kathy Hochul delivered her State of the State address as the first woman to be elected Governor of New York. That is worth celebrating. But as the Governor herself has said, “I’m not here to make history, I’m here to make a difference.”
The State of the State serves as the Governor’s roadmap for the year, highlighting her priorities for attention, funding, and other resources. Public safety and affordable housing were the big themes of her address. She also announced a welcome $1 billion investment in mental health, among other health issues.
Here are some of the things I’m most excited about in Governor Hochul’s priorities for the year — and a few items that should’ve been on the list:
Medical debt relief: Medical debt has rightly been called “a uniquely American injustice,” and New York has been making important strides to address it. Last year, Governor Hochul signed into law measures to (1) prohibit the extreme billing practice of placing liens on patients’ homes and garnishing wages and (2) ban hospital facility fees for preventive care and require advance notice to consumers for instances in which fees will be charged. Now, she is laying out a broader plan to address medical debt, including new requirements to standardize hospital financial assistance applications, enhanced price transparency measures, and educational campaigns aimed at both consumers and industry leaders.
Enhanced access to primary care: Primary care is among the best bangs for the buck in health care; it is associated with better health and it saves money. The Governor proposes to strengthen the primary care workforce by providing sustainable reimbursement for community health workers, or CHWs, through Medicaid. New York State’s 7,000 or so CHWs are frontline public health workers who are trusted members of their communities; more than half of CHWs are people of color. CHWs are associated with improving access to care and health outcomes, addressing social determinants of health like housing and food access, and lowering health care costs. Increasing support for CHWs is one thing that could expand access to primary care.
But what we really need is to rebalance our health care spending to emphasize primary care. Despite its proven value, we chronically underinvest in primary care; only about a nickel of every health care dollar is devoted to primary care. New York should join the growing number of states that have increased their investment in primary care without increasing total spending on health care. In fact, Rhode Island increased the share of its commercial insurers’ primary care expenditures by 5% and their total health care expenditures fell by 14%.
Last year, both houses of the New York Legislature passed bills to jumpstart the process of increasing primary care investment and test out programs to identify the most promising models. 2023 should be the year that such an effort gets going.
Healthy food: I’ve written before about the urgency of addressing hunger in New York State, as well as the important role that school meals play in students’ ability to learn, grow, and be healthy. Several of the Governor’s proposals would increase access to healthy food, including in schools. New York City has undertaken an ambitious effort to transform school meals from frozen and pre-prepared items to high-quality, appealing, freshly cooked meals. Governor Hochul has now laid out a statewide plan to facilitate cooking from scratch and the use of fresh New York State farm products in school meal preparation. Other proposals include the expansion of community gardens and a grants program to cover start-up costs for farmers markets, supermarkets, and food cooperatives to increase access to healthy food in communities throughout New York State.
Those are great ideas; another opportunity, universal free school meals, could further increase healthy food access. This school year, California, Maine, Massachusetts, Nevada, and Vermont are all providing free school meals to all students. Albany, New York City, Rochester, and Yonkers already provide universal free school meals to public school students regardless of income, but approximately 30% of all public school students elsewhere in the State don’t have the same access. Feeding those students would be a smart investment given the benefits associated with free school meals for all: better physical health, mental wellbeing, and academic performance; reduced stigma and shame associated with eating the school lunch; and lower costs per meal as schools can realize larger bulk discounts with more participation.
Investments in veterans’ health: Veterans are twice as likely as their civilian counterparts to experience food insecurity. Particularly since the onset of the pandemic, New York has developed creative ideas to address veteran food insecurity, including programs to deliver free meal kits to veterans and their families across the State. Now, Governor Hochul has announced plans to expand the FreshConnect program, which provides checks for veterans experiencing food insecurity to get fresh produce and other food items from farmers markets. That’s another great initiative.
Yet perhaps the most critical issue facing New York’s veteran community, veteran suicide, wasn’t addressed in the State of the State. Suicide rates among veterans are twice as high as among the civilian population. And although the rate of veteran suicide in New York State appears to have stabilized in recent years, warning signs suggest that progress is fragile: rising drug overdose deaths, firearm use in suicides, and nationwide increases in suicide deaths overall indicate that veteran suicides could again be on the rise. Ongoing efforts like the Governor’s Challenge to Prevent Suicide Among Veterans and New York State’s Suicide Prevention Task Force are focusing energy, attention, and financial resources to address the problem; community-based organizations are also doing important work to prevent veteran suicide. Now is not the time to take our foot off the gas; instead, this is the moment to redouble efforts to produce a genuine and sustained decline in veteran suicide rates.
In addition to substance, this year’s address had the traditional pomp and circumstance surrounding it. Whether you like pageantry or not, it was another sign of normalcy as we approach the three-year anniversary of COVID-19. Now it is time to keep COVID in check, and to address health issues beyond the pandemic. The Governor has laid out a compelling set of priorities and missed a few opportunities. There are a lot of good ideas worthy of support and more ideas that should be on the table. As this year unfolds, we’re all ready to work together to make a difference.
By David Sandman, President and CEO, New York Health Foundation
Published in Medium on January 12, 2023