Rural Health Fractured: The Intersection Between Food Insecurity & Rural Health

JH: Oh my God, that is amazing. That is so cool. Well, that is certainly one way to have a little bit of relief from the craziness that’s happening all around us, which we’re going to jump into in just one moment. So, we have a lot to talk about, and we’re going to unpack that here in just a second. Access to food is a key determinant of health in any community. Amanda’s expertise on food security will be vital in helping us understand the impact food insecurity has on small town America, and we’ll ask about food security programs, policy changes, which there’s a lot, and of course, what all this has to do with rural health in our communities.

So, we’re hearing more and more as I go to conferences and as we open up our periodicals and we’re reading articles about the Food is Medicine program, there’s topics, there’s seminars about this. So, let’s talk a little bit about from your perspective, you’ve worked in it, you’ve been emerged in it. So, what are the goals of the program and what possible impact would you say it’s made so far? We’re going to talk about the future of it, but let’s talk about the history, what it is and what you’re seeing.

AB: So, Food is Medicine is a broad array of programs and interventions that address food and nutrition security for primarily low-income folks that are served by the Medicaid program. And so, this work exists on a continuum, and there is a food as medicine pyramid. That’s a really useful framework for thinking about how all of the aspects of food as medicine intersect and overlap with each other. So, at the top of the pyramid, there are those clinically intensive acute Food is Medicine interventions like medically tailored meals and produce prescriptions, and those are really supposed to be short term clinical interventions to address individuals short term health needs. So, thinking about if someone has hypertension or heart disease, how can a medically tailored food box help support them in going through that acute health condition?

Then as you work your way down the Food is Medicine pyramid, there are these federal food support programs like SNAP or the Supplemental Nutrition Assistance Program, and WIC which is the same thing, but for women, infants and children. That’s to provide more long-term systemic food access. So, coupling those intensive clinical food as medicine interventions with those longer-term federal food support programs, you’re really supporting, like the whole person and the whole family in accessing long term food access and support to help meet their health and whole person care needs.

JH: And that’s all predicated on the fact that there are programs or funding that is able to be distributed to communities to engage in these programs because they’re costly. Their involvement is typically found within the state government, who offers some type of program that can supplement food in many areas, whether it’s the food stamp program or whatever the program is. Beyond that, food, food programs. The issue at hand today is what Congress did last year, known as H.R.1. The bill itself has gutted Medicaid as we know it today and by 2032, it’s going to have a much different look with the implementation starting even this year in some states. Michigan is lucky we have a little reprieve until 2027. It’s not much. Then in 27 significant financial cuts in reimbursement to Medicaid programs.

So, I guess, how has that legislation, you’ve done a lot of great work so far, a lot of planning and programs ahead, but how has this legislation impacted some of that work, and what are you expecting to see from that which will start here in 2027? What impact is that going to have on food distribution in general? I would assume families are going to be unable to access nutritional food for meals, but we need you as the expert to tell us how dire is this? What is what is your prediction?

AB: So, H.R.1. is a massive federal budget law to manage federal spending. We think about it every day in our work because, like you mentioned, while a lot of the funding changes tied to H.R.1. for Medicaid specifically are set to start in 2027 I think we could start feeling the effects much earlier, as states and health systems and community organizations really begin planning for reduced funding and increased financial pressure and just general uncertainty. So, I think when states face tighter Medicaid budgets, there is a concern that investments in more innovative preventative services like Food is Medicine could be cut.

Also, Medicaid cuts from H.R.1. are coinciding with massive SNAP cuts also through H.R.1. I don’t know if a lot of people know this, but SNAP and Medicaid often share a junkie eligibility where qualifying for one program helps satisfy the requirements for the other. So, for example, if you qualify for SNAP, you can automatically be enrolled into Medicaid in some states. So, when folks fall off their SNAP benefits because either they’re eligibility tightens or benefits are reduced more generally, we could see folks falling off the Medicaid roles as well. So, because of all of this, I think we will see a very big increase in demand on emergency food systems like food banks.

We did in this past November when SNAP benefits were halted as a result of the federal shutdown. So many of these food banks are already stretched so thin. I was at a food conference recently, and somebody from a food bank stood up as people started talking about all the impacts of Medicaid and SNAP cuts and being like, we’re going to have to rely more on food banks and the food bank representative raised their hand and he said; free food isn’t free. We still have to support all the folks that are working at the food bank. We have to make sure that they’re like sustainable pathways for the food bank to be paid for the staff of the food bank to have to support all of this increased demand. So, I think that there’s a lot of potential negative impacts of H.R.1. for sure. I will say one bright spot is that part of H.R.1. is the Rural Health Transformation Program, which is a $50 billion federal initiative that gives certain amounts of money to each state, specifically to invest into rural communities. So, a lot of states plans include some sort of food and nutrition access component so, I think that that is like the potential bright spot in all this, to see how states leverage that funding to support rural, healthy food access.

JH: That’ll be for another discussion, because as the states are prioritizing their funding allocation and distribution, we’re finding there’s quite a bit of mixed messaging there. That’ll be for a later show. Right now, are you hearing from your colleagues across the country in different states? Is this already started to impact any particular state that you know of in terms of these types of cuts? There are some eligibility reporting requirements, but has it has it reached to that level yet?

AB: I don’t think it’s reached that level yet. I think the biggest thing that states have to start implementing are those new federal work requirements for SNAP and Medicaid, and I think those have to be implemented like the first states have to do that by the end of 2026. So, there’s a lot of work happening behind the scenes right now as states deal with the administrative burden of increased work requirements and making sure that they have all of those systems set up in place for the start of 2027. I would say what we’ve heard from states is that states are working on one issue at a time. So not catastrophizing all of the changes that are coming down the pike and H.R.1. but just dealing with one issue at a time as a way for them to, like, manage all of the chaos that is coming down from the federal government.

JH: Definitely very concerning of what we’re hearing and seeing just in the preamble to the legislation. Again, its impact and effect will come in 27 to 32. I think that’s what we have to prepare for is getting ready for a significant amount of the population that will be kicked off the Medicaid program. The impact then for SNAP, those benefits will be diminished for those families. You have to talk about, as we move this forward, what are the other options available for those who are not as fortunate to qualify for benefits such as Medicaid, because there’s going to be a significant amount that fall off. So, we’ll talk about that into the future.

Before we jump into any of those details, can you help our listeners understand why our rural communities more susceptible to food insecurity? You do hear a lot about rural communities having the biggest impact in those areas. You know what nutrition related health conditions are more prevalent among rural community members as a result of that food insecurity. So, it’s a twofold question, but maybe you could help us answer it.

AB: So, I think we have to remember that food access is about so much more than whether or not a grocery store exists. It’s also about distance and infrastructure, and many rural communities are considered food deserts, where families need to drive 30 minutes or more just to access affordable, healthy food and even when the food is available locally, it’s often more expensive and there are fewer fresh produce options. Also, economic factors play a huge role. Rural communities tend to experience higher rates of poverty and underemployment, and economic instability, and food intersects with all of these other everyday needs that we have to think about, like housing and utilities and the price of gas and childcare and healthcare, all of which are expenses that are increasing. So, when budgets are tight and families are forced to make impossible choices between putting food on the table and covering other essential expenses, things can just get really bad really quickly. Because of that, we do see higher rates of diet related health conditions like diabetes and hypertension and heart disease and obesity in rural communities, because food insecurity can not only make these conditions harder to prevent, but also harder to manage, especially when healthier foods are unaffordable or inaccessible.

I really just want to stress that food insecurity is not about people failing to make healthy choices. It really reflects the choices available to them within these broader structural and economic constraints. When we hear about things like these SNAP waiver restrictions that are being put into place, that are preventing folks from using their SNAP to purchase health like unhealthy foods like soda or energy drinks, that’s not really addressing the problem. Folks would spend their SNAP dollars on healthy produce if that gave them the same amount of calories to get them through the day. As these like more quote unquote unhealthy food items. But folks are just doing their best to get through the day. Rural communities are resilient, but they are dealing with so many structural challenges.

JH: Let’s talk about communities, because the impact of food insecurity has a relationship on the economic well-being of our respective communities. Can you talk about that correlation?

AB: So, at a community level, food insecurity is associated with higher healthcare utilization and costs because these unmanaged chronic conditions that we’ve already talked about are at higher rates in rural communities, lead to more emergency room visits, more hospitalizations, and more complications over time. Rural hospitals and clinics are also already operating on thin margins. These higher levels of preventable illness can and do place additional strain on the healthcare system. There’s also an economic impact on workforce productivity when people are struggling with hunger or these diet-related chronic conditions, it can affect attendance and concentration and energy levels and long-term workforce participation. Parents might also have to miss work to care for a sick child. Even children experiencing food insecurity face challenges in successfully completing school, and that affects educational attainment and then future economic opportunities.

So, this is really a cycle of poverty and a cycle of food insecurity that has to be addressed. I’ll also just mention that local communities are also impacted by these H.R.1. cuts coming down, especially as they relate to SNAP, because SNAP dollars bring federal money directly into local communities and they help to support grocery stores and farmers markets. So, when benefits are reduced or unstable, businesses are going to feel the effects too. I will say that I think Food is Medicine is a real bright spot as an opportunity to strengthen local communities because through local food procurement, hospitals and health plans, and community-based organizations can source food from local farmers and producers for medically tailored meals and produce prescriptions. Those investments can stay within the community rather than leaving it. So that really helps to ensure that foods are not only local and supporting the local economy, but also culturally responsive to the community needs.

JH: It could be a great partnership. It really could be. You reach out to some of your local farmers and it can have a significant impact on them and to the community when you find a partnership. We did that several years ago, and we had worked with several of our farming community members. We wanted to make sure that we supported them in this process, not just by bulk food from a distribution center, but also making sure that we had good nutritional food, fruits and vegetables for the community is so important because access to those in rural communities are almost non-existent. We’re hearing more and more and more about the social determinants of health.

Amanda, you hit the nail right on the head when you said the impact of food insecurity on the well-being of the person, their ability to go to work and to function fully in that day, if they do not have the nutrition that they need and those types of things impact, the social behaviors and habits of our populations. We start to see that in in the workforce. This is why if you trace back to decades ago, free lunch programs were established in schools because they identified even in testing, that if a child is at school and they receive their lunch and their meals, their attendance is better, their testing scores are better, they’re more alert, they’re making better decisions. Truly those are the basic things we knew about 30 years ago when I was getting free lunch as a kid. I recall the importance of what that is.

Today we’ve discarded it all with H.R.1. We’ve essentially said that there’s a lazy population of fraud, waste and abuse, which is not true. The faces of the children that we see every day, whether it’s the pastor of the church who gets support or if it’s the mom at the Dollar General, these are the faces of SNAP and Medicaid. It’s not waste. It’s not fraud. It’s not abuse. Sadly, that narrative has been told far too often and believed by many and we have to change that. We owe it to our communities to be the voice. You’re doing just that, Amanda, every day, by talking about and putting into action sustainable programs for food securities. I want to commend you for that work. But it does bring us back into that full understanding of what the social determinants of health are and how these play a vital role. So great work with what you’ve done to educate the communities, to build partnerships, to understand the economic impact to communities when you have these types of programs. I guess as we conclude today the call to action, I think has to be stated, and that can be “how”. You have listeners across the country. How can we as healthcare leaders, better coordinate food security access across systems like SNAP and Wick? And, you know, the future of these funding programs are being cut. How do you better coordinate and sustain that? What advice would you give to the community to be able to achieve that?

AB: I think you said it as well, but we need to center the human in all of these public benefit programs that have been politicized in so many ways, but our are its core, just a fundamental human right to have access to healthcare, to have access to food, to have access to housing and to safe spaces to play. I think what it comes down to is thinking about how we can improve coordination across all of these systems to support easier access for the folks that need to use these programs. So many of these programs are independently operating in silos, and we need to break down these silos and have folks work across sectors to make sure that folks are able to access the things that they need.

So, thinking about specifically how we can better coordinate and align SNAP and WIC and Medicaid, it’s really going to be about better data sharing across systems so that folks don’t have to submit a bunch of applications to apply to all of these disparate programs, just to apply once, and that gets them access to SNAP and Medicaid. It’s also about coordinated screening and referral processes, from healthcare organizations to community-based organizations, so that folks have to be screened once to then access the food that they need, and then thinking about how we can streamline technology and interoperability across all of these things that folks don’t have to get a call being saying, hey, we actually don’t have the paperwork that we need, can you give all your information again? That’s just additional burden on families, an additional burden on these folks that are already doing the most they’re working multiple jobs. They’re caring for children, they’re caring for elderly family members, and they just want to put food on the table at the end of the day. So, I think doing all of those things to center the member experience, as well as we just need to keep talking about this and elevating food as a health issue. The more by in that we get from leaders across all of these different sectors, the easier it will become to build these cross-sector solutions that will really be able to be sustained over time.

JH: Great, great responses. I believe what we hear echoing very loudly is advocacy, engagement, communication, telling our story. If we can accomplish those four things, we’d be very successful. I’m going to encourage our listeners today, if you have a compelling story, get it before your congressional leader about the impact that Medicaid or SNAP programs or WIC programs has had in your respective community, let your elected officials know that they get caught up in this discussion back and forth. It’s politicized to the highest degree ever in our history. We forget the human element. We forget who stands in the balance. The young child who doesn’t have access to food, who goes to school hungry, who in the summer has no access to food, in food programs. These are the things that we have to keep at the forefront. So, continue to do the great work that you’re doing Amanda, each and every day, we truly appreciate this type of work. I have been, just, educated in in the work that you have done.

We’re going to drop your information into our show notes for others that may want to reach out to you, to try to learn how to duplicate these types of programs and advocacy in their community. We’re going to put your information in so they can reach out to you. It’s really just raising awareness. So, thank you so much for lifting your voice. When you lift it for your community, you’re lifting it for every one of our rural communities across this country. So, thank you for doing that.

AB: Just to build on what you said, something that I heard one time was “lived experience is expertise”. Never diminishing what you’ve been through because that is what could create the biggest impact is sharing your story and letting folks know what you need.

JH: Very well said. Well, it’s hard to believe that our time is upon us. At the conclusion of each of our podcast, we like to do a little segment called Rural Health Recommendations. This provides us an opportunity to ask a leader like yourself, who has a vast amount of experience in a lot of areas, what recommendation, what tip, what sage advice would you give to a new leader? Maybe it’s someone in your position in another state that’s really struggling to identify funding programs, outreach, communication. We live in some very tumultuous times right now. It’s very tense. There’s a lot of dialog. There’s a lot of negativity. What advice would you give a new leader who’s trying to rise up and conquer some of these challenges?

AB: I think my recommendation is sort of mindful. Just a reminder that this work is so deeply human and for many of us, deeply personal. Either we have been on food stamps growing up or the national school program, or we know people who have. So doing this type of work is really heavy right now, and there can be a lot of moral injury and emotional weight to do this work every day. Something that I try to do is just take small moments to regulate my nervous system, to reconnect with myself. Doing this work every day and thinking about all of these problems every day that are only seeming to get worse, can leave us in a constant fight or flight state, and it can be very destabilizing. A simple practice that I come back to is just focused on breathing. When you breathe out longer than you breathe in, for example, breathing in for four and breathing out for six, that extended exhale, scientifically, helps to calm your parasympathetic nervous system, which can help ground you even in really stressful moments. I know that sounds like a small thing, but I think sustainability comes from small, repeatable practices that help us really stay centered and present. Caring for ourselves is a big part about being able to care for others.

JH: Well said, my friend. Care for yourself and then you know what? You can go out and conquer the world with initiatives like you have engaged in and I fundamentally believe that, but you got to be, well, yourself. Great advice that you’ve given us today, Amanda, thank you so much for joining us in the studio today. It’s been great to get to know you and get to know about your program and to really learn about how we can educate other communities across this country about the importance of food security, how we obtain those, and the relationship with social determinants of health. So, thank you so much for being a part of this today.

AB: Thank you for having me. It’s great to meet you.

JH: And thanks to our listeners for tuning in to Rural Health Today. Catch our next segment, Rural Health News to stay up to date on the current state of rural health every Monday, wherever you get your podcasts. Don’t forget to check out our latest updates and resources from Rural Health Today at ruralhealthtoday.com, and make sure you subscribe so you never miss an episode. Until next time, remember Rural Health Strong.