Every other Friday, the Stockton Emergency Food Bank hosts two live cooking classes -- one in English and one in Spanish. Last week, Brenda Munoz made a classic tuna melt with an orange, romaine and dandelion salad.
"Dandelion is completely edible," said Munoz, holding the small leaves from the flower. "They're really high in vitamin A and folate."
But this isn't your typical cooking lesson on Zoom and Facebook. It's part of a "food prescription" experiment -- prescriptions for healthy food instead of pills. Diabetics get a free box full of fruits, vegetables, chicken breast, quinoa and other nutritious food delivered to their homes every two weeks -- and then can learn some recipes.
Advocates who want to expand the program across California say it could very well be a way to improve chronic conditions, lower health care costs and reduce hunger, all at the same time.
It's aimed at people like Shane Bailey, a 72-year-old who served in the Coast Guard who has three heart conditions, diabetes, kidney disease, high blood pressure and cholesterol. A participant in the Stockton food bank's Healthy Food RX Program, she says her lifestyle has dramatically improved since she began receiving produce prescriptions last year.
"My primary doctor is impressed with my cholesterol because they say it's better than theirs!" said Bailey, who has started meal prepping using cookbooks from second-hand stores, reading food labels closely, and experimenting with different kinds of squash and greens.
"My dream is to live to 95," she said. "If we start younger, then maybe people won't get sick until they're in their 80s and 90s."
Food prescriptions are part of the "food is medicine" movement that views nutritious food as a way to prevent, manage, and reverse chronic disease. Such programs have been found to lower obesity, blood pressure, and average blood sugar. One study estimates that incentivizing healthy eating could save $100 billion in national healthcare costs over the projected lifetimes of current Medicare and Medicaid patients.
Across California, a patchwork of food prescription programs are being tested using a variety of strategies, while an ambitious initiative to reform Medi-Cal and a bill that failed in the Legislature this session would standardize the effort.
A California experiment
At the beginning of 2022, California launched a five-year effort to reform Medi-Cal, called CalAIM, to address the root causes of diseases based on "whole person care," which considers biological, behavioral, social, and environmental factors.
CalAIM encourages Medi-Cal managed health plans to experiment, allowing them to opt in to provide 14 optional community support services, such as housing navigation, assisted living and sobering centers.
The goal: Improve the health of Medi-Cal patients with lower-cost treatments. By the end of 2022, all 58 California counties offered at least two community services, while 16 counties offered at least 10 and three counties -- Sacramento, Riverside, and San Diego -- offered all 14.
Medically supportive food programs, which include medically-tailored meals and food prescriptions, are the third most popular service. In 2022, 6,400 Medi-Cal members used food programs, the vast majority of the more established medically-tailored meals program.
Katie Ettman, a food in healthcare expert at the San Francisco nonprofit research institute SPUR, said there is vast potential for food programs, considering that California has the largest Medicaid program in the country with about 15 million people enrolled.
But the challenge is getting counties and health plans to start them.
"The vast majority of them don't even know how produce prescriptions work," said Brent Ling, director of external affairs at the nonprofit Wholesome Wave. "So it's a lot of education and information sharing."
There are also a variety of food prescription programs being funded outside CalAIM. The Stockton program is being financed by the philanthropic Abbott Fund, Kaiser Permanente is funding a test in Los Angeles County, and programs in San Diego County and San Francisco are being funded by their local governments.
The federal Farm Bill is funding 14 food prescription tests in California. One is Recipe4Health in Alameda County. What started as a food pharmacy program in 2019 has evolved into California's most successful medically supportive food program that is integrated into the county's healthcare system.
The program has 11 sites across Alameda County and serves almost 4,000 people according to Steven Chen, its chief medical officer.
Chen believes the testing across California is an important stage to make the services a permanent benefit under Medi-Cal: "Any innovation starts with fragmentation because it's a 1,000 flowers bloom approach... You want to create enough openness because otherwise, it's just a top-down approach, which never works."
Alameda County screens for food insecurity and offers people who might not have chronic conditions prescriptions and health coaching to prevent diseases like diabetes from developing in the future.
"There's so many benefits," Chen said. "We're getting human health, economic health, climate, health, and equity all together by really asking the question, 'Where does the food come from?'"
A covered benefit?
This session, Assembly Bill 1644 was introduced that would have required Medi-Cal to cover medically supportive food and nutrition for at least 12 weeks for eligible Californians.
"I remember opening the fridge and seeing only celery and peanut butter and my mother telling me we were on a 'special diet'. I did not realize at the time we were food insecure," said Assemblymember Mia Bonta, an Oakland Democrat who proposed this bill. "Too many Californians, particularly Californians of color, are living with largely preventable chronic conditions."
While Bonta highlighted how this bill would help the state save money in the long run, its estimated cost was in the tens of millions of dollars. With the $30 billion-plus state budget deficit, the bill was held in the Assembly appropriations committee.
Bonta's office and bill co-sponsor at SPUR said that they plan to reintroduce the bill next year.
National momentum for food prescriptions is growing. Last year, the White House released a national strategy on hunger, nutrition and health that prioritizes "food is medicine" interventions including food prescriptions.
Combined with grassroots efforts across California, the bill will gain momentum, Ettman said.
One successful local program is in Solano County, where Rich Oliver drives a colorful box truck painted with crates of fruits and veggies to clinic parking lots during the week.
"We are purposely outside of clinics because we want patients in the clinic to have access to this," says Oliver, who is the coordinator of the county's "mobile food pharmacy."
The program began in 2018 when the county partnered with the local food bank and the Yocha Dehe Wintun Nation, a federally recognized native tribe. From April to June this year, the truck served 16,000 people, according to the Food Bank of Contra Costa and Solano.
At county clinics, providers give patients facing food insecurity or diet-related health conditions a paper food prescription. If the food truck is there that day, patients can then stop by the nearby truck or parking lot.
On Tuesday mornings, the truck parks outside a Fairfield health clinic. Last week, Jose Leyva, a 67-year-old Suisun City resident on disability, handed over his wife's prescription and received potatoes, onions, cantaloupes, lettuce and a 25-pound box of pantry staples.
"We don't have much money for the grocery store because it's too tight," says Leyva, who regularly picks up food from the truck for his diabetic wife. "This helps a lot."