Imagine you are the tightfisted potentate of a small republic, plotting the least expensive way to care for subjects in fragile health who depend on your beneficence.
You could watch while your subjects who are elderly or disabled (or both) scramble to find and pay for healthy meals. And you could open your checkbook each time one of these subjects lapses into a health crisis that calls for a trip to a hospital's emergency department in an ambulance.
But you might just try feeding these needy subjects instead.
A study conducted in Massachusetts suggests that making regular deliveries of meals to people who were deemed "food insecure" drove down their use of costly medical services such as emergency department visits, ambulance calls and, in some cases, hospital admissions.
The net savings to a budget-conscious ruler, even after providing meals to her subjects free of charge, could be at least $10 per subject per month.
A more specialized program that provided meals targeted to recipients' special medical needs yielded monthly savings as high as $220 per person.
The new study offers some clear evidence that even costly nutrition programs can pay handsome dividends when they are focused on low-income Americans who tend to have especially complex medical problems.
Those benefits translate not only into healthcare savings for governments or other program sponsors, said Dr. Seth A. Berkowitz, the study's lead author. They mean improved health for the people these programs feed, he said.
The study was published Monday in the journal Health Affairs.
Berkowitz and his colleagues measured the impact of two types of meal programs on a population at very high risk of experiencing health crises: adults who are eligible for both Medicare (the federal health insurance for seniors) and Medicaid (the state and federal program that provides health insurance for low-income people and those with disabilities). Study participants also had to face difficulties getting and paying for healthy food and/or preparing meals for themselves.
The authors of the new study took advantage of an ongoing health insurance program in Massachusetts to measure the impact of supplemental feeding initiatives. In one group they followed, 133 people got five days' worth of lunches, dinners and snacks delivered once a week. These meals were tailored to their individual medical needs, such as diabetes, kidney disease and digestive problems.
The second group, of 624 people, got daily deliveries of a healthy lunch and dinner that were similar to those provided by Meals on Wheels.
Over a period of 18 months ending in June 2016, the healthcare usage of each group was compared to those of two much larger comparison groups of Massachusetts residents composed by the researchers. Collectively and individually, those in the two comparison groups had similar health and income challenges to those who got meals delivered. But they fended for themselves at mealtimes.
Compared to their self-catering peers, participants who got the medically-tailored meals had 70% fewer emergency department visits and fewer than half as many hospital admissions. They called an ambulance for transport to the hospital — a very costly service — 72% less often than those in their comparison group.
Participants who got the less customized meal-delivery service showed improvements that were slightly more modest. They had 44% fewer emergency department visits than their comparison group, had 12% fewer hospital admissions, and were 38% less likely to call for an ambulance.
Existing research shows that feeding programs (such as federally funded food stamps and the Women Infants and Children, or WIC, program) are effective at reducing food insecurity and improving nutrition, Berkowitz said. But it's been harder to find research showing that such programs improve health — and yield healthcare savings by doing so.
One 2013 study in Health Affairs projected that if every U.S. state in the lower 48 expanded the number of seniors receiving meals by 1%, 1,722 fewer Medicaid recipients would need to live in a nursing home. Expanding programs like Meals on Wheels would save 26 of 48 states money, that study found. And most states would experience a net annual savings from implementing the expansion.
For states or organizations looking to improve the health of some of the most vulnerable Americans, "there's real potential here," said Berkowitz, an internist and public health specialist at University of North Carolina's School of Medicine who conducted the research while at Massachusetts General Hospital.
This is a population, he added, in which "it's been hard to move the needle." For these study participants, the provision of meals that were nutritious, prepared and delivered directly to the home appeared to be the key to improving health.
New York University food and nutrition expert Marion Nestle, who was not involved with the study, called the savings almost too large to be real.
"If it were that simple: you just have to give people meals to keep them out of hospitals?" Nestle said. "Wow! I'm for it!"
"Yes, people should get fed. And having people eat healthfully is a really good idea," she added. "The idea that it would help reduce healthcare costs makes perfect sense, and it's wonderful to have evidence to demonstrate that."
The new study comes against the backdrop of changes in federal health spending and state Medicaid programs that are unlikely to make services more generous.
Just a year ago, the Trump administration proposed substantial cuts in federal programs that help fund initiatives such as Meals on Wheels. And states are being offered wide latitude in scaling back services or imposing new conditions on Medicaid recipients.
Last year, Mick Mulvaney, President Trump's budget director, defended proposed cuts to the Community Development Block Grant program, which is widely used to help fund Meals on Wheels.
The program "sounds good," Mulvaney said. But he bemoaned the dearth of evidence for its benefits. He promised the administration would propose cuts "on programs that cannot show that they actually deliver the promises that we've made to people."
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