1115 Waiver Recommendations
Kelly Cunningham
Medicaid Administrator
Division of Medical Programs
Department of Healthcare and Family Services
201 South Grand Avenue East, 3rd Floor
Springfield, IL 62763
RE: Recommendations for implementation of food and nutrition benefits in Illinois’ pending 1115 waiver
Dear Administrator Cunningham:
Please accept this letter on behalf of food is medicine partners across the state of Illinois who support the Department of Healthcare and Family Services’ efforts to design and implement the Illinois Healthcare Transformation Section 1115 Demonstration. We truly believe that this waiver could situate Illinois as a leader in addressing health related social needs across a wide range of populations and settings.
The purpose of this letter is to outline five key values that we recommend guide the Department for implementation of our state’s 1115 demonstration extension. As the waiver is pending approval, we believe this is a critical moment to build a robust foundation for the years ahead. We recognize implementation of this waiver requires unprecedented coordination, infrastructure development, and systems change in order to be successful. Although many states like Massachusetts, California, New York, and North Carolina have in part paved a path forward for Illinois, we are nonetheless confronted with ambiguity as we strive to create novel approaches that suit the needs of Medicaid recipients in our unique context.
As partners of the Alliance for Health Equity’s Food is Medicine Subcommittee, we have a vested interest in expanding food and nutrition benefits across our state. Poor diet is a leading driver of death nationally and food insecurity is associated with increased risk of the costliest and deadliest chronic diseases. Additionally, research has shown that food insecurity and housing instability share a bidirectional relationship – families who experience food insecurity are at increased risk of experiencing housing instability and vice versa. Families who experienced both food insecurity and housing instability were more likely to be racial/ethnic minorities and socioeconomically disadvantaged. The research also found that programs to address these needs tend to operate in isolation and consolidating them could better address hardship. Food is medicine programs like those in the waiver have immense health, cost-savings, local food systems, and local economic development benefits. To best support Illinoisans and maximize the waiver opportunity, we thus encourage early implementation of these benefits in coordination with housing, medical respite, and reentry.
The values expressed in this letter are also informed by national food is medicine groups like the Food is Medicine Coalition (FIMC), Center for Health Law and Policy Innovation at Harvard Law School (CHLPI), the Food is Medicine Institute, Friedman School of Nutrition Science and Policy, Tufts University, the National Produce Prescription Collaborative (NPPC), and the Medicaid Food Security Network. Leaders from each of these groups have expressed support of this letter and are willing to provide consultation to Illinois as we plan for implementation. A detailed version of the values presented can be found in our addendum on the Illinois Public Health Institute website.
VALUE 1: Collaborate with multisector partners to inform implementation
Ongoing engagement of key stakeholders across the state is essential during planning and implementation of the waiver. We recommend the inclusion of food is medicine partners, such as healthcare providers who are making referrals like primary care providers, dietitians, and community health workers; WIC clinics; small scale community-based organizations; socially disadvantaged growers, producers, vendors, and prepared meals providers; food banks; values-aligned for profit partners; and Medicaid managed care enrollees. We also encourage the Department to collaborate with state and federal agencies and coalitions, such as the Department of Agriculture, the Department of Human Services, the Lieutenant Governor’s Office, the Illinois Department on Aging, the Illinois Association of Medicaid Health Plans, the U.S. Department of Agriculture, and the Centers for Disease Control.
VALUE 2: Create community care hubs and fund other infrastructure
Although there may be some indication that CMS prefers community-based providers to become enrolled Medicaid providers, this is subject to change. We also recognize that the Department sees the importance of small-scale community-based organizations and a community-based approach to delivering services. To ensure that these partners, in addition to socially disadvantaged growers, producers, and vendors, have the appropriate resources or capacity to bill managed care, we suggest that the Department use infrastructure funding in the waiver authority to build community care hubs. Similar models are seen in North Carolina and New York, and the pending application planned for Pennsylvania. Through these hubs, the benefits could also be rolled out in tandem, creating infrastructure that will outlast the waiver extension period.
VALUE 3: Prioritize local food system development
The waiver presents us with a crucial opportunity to scale programs in Illinois and reinvest dollars in our state and local food system development. We encourage the Department to follow the lead of states like Hawaii and keep the majority of waiver investments in Illinois and to incentivize managed care plans to allocate a certain percentage of purchases from local socially disadvantaged growers and producers. We also suggest the Department take advantage of preexisting partnerships and infrastructure, such as those developed through planning for the Local Food Purchasing Agreement. Lastly, the Department should take steps with state actuaries to ensure that the reimbursement rates for food and nutrition benefits are substantially sufficient such that healthcare and community-based organizations have the appropriate financial resources to purchase food locally.
VALUE 4: Rigorously evaluate pilots
Coordinated evaluation of the 1115 demonstration is critical to ensure that the pilots can evolve and inform what benefits should be sustained beyond the waiver. We encourage the Department to consider partnerships with universities and other research entities in Illinois. The North Carolina Department of Health and Human Services modeled this practice by partnering with the University of North Carolina to plan and implement rapid cycle and annual assessments over the course of their waiver. We also emphasize to the Department the importance of outcome-focused evaluations during implementation, transparency in data sharing across sectors, and aligning key research questions with the White House National Strategy on Hunger, Nutrition, and Health.
VALUE 5: Support other food and nutrition programs outside of waiver
We encourage the Department to consider that our 1115 waiver is just one of many initiatives aimed to address health related social needs amongst Illinois’ most vulnerable communities. The Department, with support from agencies working on SNAP, WIC, the Older Americans Act, and other food and nutrition policies, like the Department of Human Services and Department of Public Health, should first 2 take steps to definitively outline to the public which populations are eligible for which benefits and how to access them, especially in instances of dual eligibility like those who are part of the MedicareMedicaid Alignment Initiative. Once eligibility has been made clear, we encourage the Department to use infrastructure funding from the waiver and leverage innovative partnerships to strengthen access to and enrollment in programs that would benefit all vulnerable Illinoisians.
We thank Administrator Cunningham and the Department for your thoughtful consideration of these values. We invite any questions or comments.
Signed,
Access Community Health Network
AgeOptions Ascension Saint Mary - Chicago Advocates for Urban Agriculture Advocate Health Care AIDS Foundation Chicago AllianceChicago Alliance to End Homelessness in Suburban Cook County Ann and Robert H. Lurie Children's Hospital of Chicago Arab American Family Services BEDS Plus, Inc. Beyond Hunger The Boulevard of Chicago Chicago Department of Public Health Chicago Food Policy Action Council Chinese American Service League Circle Urban Ministries Citizen Action/Illinois CocinaRx The Common Market Common Pantry Common Threads Cook County Health Equal Hope Feeding Illinois Finding Justice A Flower and Vegetable Garden FoodHero Good Food Catalyst Greater Chicago Food Depository The Harbour Housing Action Illinois Humboldt Park Health Illinois Association of Area Agencies on Aging Illinois Coalition Against Domestic Violence Illinois Collaboration on Youth Illinois Farmers Market Association Illinois Food Justice Alliance Illinois Partners for Human Service Illinois Public Health Institute Illinois Stewardship Alliance The Inner Voice, Inc. Japanese American Service Committee JOURNEYS | The Road Home Marillac St. Vincent Family Services Metropolitan Family Services Midwest Foods Niles Township Government Northern Illinois Food Bank Northwest Compass, Inc. Nourishing Hope Offshootz Peoria Area Food Bank Real Foods Collective Renaissance Social Services Rush BMO Institute for Health Equity St. Louis Area Food Bank Shriver Center on Poverty Law Start Early Swedish Hospital Thresholds Together We Cope Top Box Foods United Nations Association USA of Greater Chicago Wards365 Westchester Food Pantry West Side United Windy City Harvest
Read the addendum to the letter with detailed values - April 3, 2024