Knee surgery in 2021 limited Elizabeth Duran’s physical activity and caused her to gain weight. Duran, 65, took pills for high blood pressure and dealt with her anxiety privately.
In the fall of 2023, her doctor referred her to a county program, Recipe 4 Health, that delivers fresh produce to her house. Duran, who is Hispanic, credits the program with getting her back on track.
“I was familiar with Swiss chard and kale,” said Duran, “but I never would really choose those things.” After learning their nutritional value in the program, she looked up how to cook them.
Duran said participating in Recipe 4 Health helped her control her blood pressure, sleep better, and reduce her anxiety.
Since its inception in 2020, Recipe 4 Health – part of the “food as medicine” initiative – has connected over 6,000 Alameda residents, 83 percent of them people of color and more than half Spanish speaking, to healthy vegetables and health coaching. The results are impressive.
“One third of our patients with prediabetes and diabetes show a clinically meaningful reduction in their blood sugars,” noted the program’s chief medical officer, Dr. Steven Chen. “Two thirds of the patients improved their cholesterol indicators, thus reducing heart disease risk” while “44 percent of our patients are reducing their depression symptoms.”
Such outcomes can help prevent chronic illnesses and cardiovascular disease which ultimately save healthcare dollars, said Chen. He believes that consistent funding for Recipe 4 Health is critical to its longevity.
Currently, Recipe 4 Health receives much of its funding from CalAIM, a multi-year initiative that combines federal and state dollars to address social drivers of health, including food and housing insecurity.
The state Department of Healthcare Services (DHCS) administers CalAIM, and funds local Medi-Cal plans to reimburse programs like Recipe 4 Health that provide medically supportive nutrition.
DHCS was granted a five-year extension for federal funding for CalAIM, which was previously set to expire in Dec 2021. As he inches closer to 2026, Chen is looking for a stable funding source for his program that does not need frequent renewal.
This is why he is urging lawmakers to adopt AB 1975, Assemblymember Mia Bonta’s (D-Oakland) second attempt to require Medi-Cal coverage of medically supported food programs. If passed, California would become the first state in the country to require its Medicaid program to cover this benefit. The bill is currently makings its way through the state legislature.
“Too many Californians, particularly Californians of color, are living with largely preventable chronic illnesses and conditions,” said Bonta, noting her measure would go a long way in advancing health equity in the state.
A majority of those enrolled in Recipe 4 Health are low-income people of color.
Every week for 3 months, program participants receive 16 servings of fresh fruits and vegetables, said Sasha Shankar, co-farm director at Dig Deep Farms, which supplies the program’s produce.
Weekly health coaching, meanwhile, helps participants learn about nutrition, exercise, and stress management, while also helping them set and meet health goals.
To participate in Recipe 4 Health, Medi-Cal patients in Alameda County need a referral from their primary care provider at participating health centers, which include Alameda Health System, Bay Area Community Health, Lifelong Medical Care, Native American Health Center, and Tiburcio Vasquez Health Center.
The program is separate from CalFresh, California’s food stamp program, and many patients are able to receive both Recipe 4 Health and CalFresh benefits at the same time.
Primary care providers can refer patients if they are food insecure, or have a chronic condition such as diabetes, high blood pressure, high cholesterol, heart failure, or stroke.
Nearly 10 percent – roughly 154,000 – of Alameda’s 1.6 million residents live in homes that experience food insecurity.
Once participants have been referred by their primary care provider, Recipe 4 Health receives the referral and passes it to the county Medi-Cal plan, Alameda Alliance for Health for authorization. The referral is also forwarded to partners Dig Deep Farms and Open Source Wellness, which provides health coaching. These partners contact the participant to verify contact information before starting services.
Still, despite its successes the program has not been without challenges. “Literally a few weeks into the program and the pandemic hit,” said Chen. “We went totally to doorstep delivery. And then we went to virtual groups.”
The pandemic had several other ripple effects on the program. As fewer people saw their primary care provider for routine care, fewer referrals were made to Recipe 4 Health.
Contact information in the clinic’s medical records also became outdated. If phone numbers were not updated in the clinic’s record, referrals would carry that incorrect information to Recipe 4 Health. When that happens, “We have data to show that drops off significantly,” by as much as 50 percent. “Wrong number, you can’t reach the patient, kind of dead in the water,” said Chen.
Lack of time or transportation can also prevent people from participating in weekly coaching sessions. In 2023, only 1,105 of 1,949 – about 56 percent – Recipe 4 Health participants attended coaching.
That has put a strain on Open Source, explained Director Elizabeth Markle, who said Recipe 4 Health is currently seeking to renegotiate its contract with the organization by moving to a fee-for-service model.
Rising inflation and food costs have also had an impact. Shankar said that Dig Deep Farms was reimbursed $23 per bag of produce delivered to participants in 2023, and that reimbursement rates had to be increased in 2024.
But compared to the billions California spends each year treating chronic illnesses, Recipe 4 Health’s per-patient outlays – roughly $785 per participant for the year, based on information provided by Chen’s team – are more cost effective.
When critics ask, “How do we pay for this food?” Chen replies, “We’re already paying for it. It’s just through our healthcare system.”
Dr. Sejal Parekh is a practicing pediatrician and a Stanford Health Equity Media Fellow.
