In North Carolina, a radical experiment targets social determinants of health with fresh produce and safe housing

Late last summer, Elizabeth Jacques brought her youngest daughter, Elena, for a medical checkup. At the time, Jacques and her family were experiencing housing instability after a two-year legal battle with their former landlord, who refused to clean up their unsanitary, unlivable conditions.

For Jacques, it was obvious she had to leave a housing situation that was putting her family’s health at risk. Black mold was growing on the walls of the trailer in which Jacques and her family had lived for five years. The mold caused everyone — Jacques, her husband, and her three younger daughters — to get more frequent headaches and stomachaches. It also impacted Jacques’ breathing because she is immune-compromised. “My ability to function as a normal human got worse and worse,” she said. Meanwhile, there were gaping holes in the trailer’s floor; Jacques fell through them in the bathroom twice.

Starting around September 2022, Jacques and her family hopped between three different hotels around Fletcher, in western North Carolina. But choosing to leave their trailer for safer living conditions meant making trade-offs. “In order to make sure we had someplace safe to sleep and to take showers, we chose hotels, and then the food was either given to us [there] or we went to a pantry,” she recalled.

At the physician’s office, the doctor diagnosed Elena, now 7, with ADHD, and said she needed to have her tonsils removed. Knowing that Jacques’ family was unhoused, the doctor also asked a simple question: What else do you need? Without missing a beat, Jacques said: food.

As it turned out, a North Carolina program designed to help families like Jacques’ was well underway.

That program, the Healthy Opportunities Pilot (HOP), is the first of its kind in the United States. With $650 million in federal funding secured in 2018, HOP aims to comprehensively test and evaluate how addressing the social determinants of health — access to healthy food, transportation, safe and clean housing, and interpersonal safety — can improve health outcomes, all the while reducing health care utilization rates and emergency services for Medicaid members. Elena was enrolled in Medicaid, which meant Jacques’ family was eligible.

In North Carolina, nearly 13,000 individuals are enrolled in HOP to date, and the food delivery services — which offer fresh produce, grains, and meat on a weekly basis — were the first to launch in earnest. So far, early results from the pilot suggest that food delivery programs associated with HOP are more effective in providing food security than those provided by food subsidies, like food stamps. A more comprehensive report was submitted in March 2023, said Seth A. Berkowitz, the lead evaluator of the HOP program at the University of North Carolina in Chapel Hill, and will be made public soon.

For Jacques and her family, even as they moved from hotel to hotel over a span of 10 months, HOP’s fresh produce deliveries were a constant. Some months, they also got food stamps, or would try pantries — but even some pantries were running out of supplies, Jacques said.

Every Tuesday, Jacques’ daughters would get excited to see the food delivery car pull up in front of their hotel. Elena was like a kid in a candy shop as she helped her mom pick out peaches, oranges, and snap peas during the summer.

Jacques said she lost 30 pounds because of her ability to access fresh fruits and vegetables from the program, even as she was unhoused. Eating well during a turbulent time was just one less thing for her to worry about, even though the rest of her life felt in flux.

The promise of produce prescriptions

North Carolina secured funding for the HOP pilot project in 2018 through 1115 Medicaid waivers, which refers to section 1115 of the Social Security Act. Such waivers give the secretary of health and human services the authority to approve pilot projects like HOP that will promote the objectives of the government’s Medicaid program. HOP, as it exists now, will run until 2024.

HOP executive director Laurie Stradley said the larger goal is to demonstrate that pilot programs like HOP should be accessible not just to people on Medicaid, but to the general population. “We really believe that this network model that brings together both clinical and social health needs should be available regardless of payer model,” she said.

Since HOP’s approval, many other states, including California, New York, Arizona, Oregon, Massachusetts, and Washington have applied for and received similar 1115 waivers.

These new waivers are unique because they focus not only on food security, but also on nutrition security, noted Dariush Mozaffarian, a cardiologist and a professor of nutrition at Friedman School of Nutrition Science and Policy at Tufts University. And because these waivers are baked into the Social Security Act, they serve as a more sustainable way for states to continue providing such services.

That the food deliveries through HOP are regular constitutes them as produce prescriptions. Such prescriptions are a proven tool to help lower blood sugar levels in low-income individuals with diabetes, decrease obesity, and reduce hypertension. They also have shown to help keep patients out of the hospital, reducing both emergency room visits and hospitalizations in nursing homes, said Mozaffarian.

“We know that when you invest upstream, that our health care dollars go down and our health outcomes go up,” said Stradley. Alongside the food prescriptions, which were the first service that HOP launched in March 2022, the program also helps individuals find stable, long-term housing, have reliable transportation, and get out of unsafe and violent living situations.

A mobile farmers market

The food delivery services that Jacques and hundreds of other families benefit from in western North Carolina have been spearheaded by a nonprofit called Caja Solidaria based in Hendersonville.

Caja Solidaria, or Caja for short, was founded by Sonya Jones, a former public health professor at the University of South Carolina. Jones left her academic post in the wake of the Covid-19 pandemic and began working for a local mutual aid organization looking to start a food bank in Hendersonville, where she grew up. Eventually, that food bank grew in members and funding.

By the time the pilot program in North Carolina launched, Caja was an obvious partner in western North Carolina. “No organization was stepping into the shoes of distributing food or healthy food prescription services,” said Jones. “I know how to buy food, I have a nutrition background. It seemed like a really amazing fit.”

Caja Solidaria sources produce, grains, and meat from local farms or distributors, and prioritizes purchasing culturally relevant foods for the families that they serve. Jacques’ husband, who is Mexican, gets excited over the spice mixes that they have the option of choosing as part of their food deliveries.

The funding from HOP also enables the nonprofit to buy directly from farmers in their communities. The family that Caja Solidaria sources chicken and pork from was struggling to find a customer base in the early days of the pandemic, said Jones, but they have since been able to increase their production every single month to meet Caja’s demand. “We’ve financially stabilized their farm and really helped them get started.”

Caja started out with bike deliveries: The food for the week would get loaded up into pink coolers and put on a wagon, hooked to a black commuter bike. With funding from HOP, the organization was able to buy a four-wheel drive van to drive to families with a mobile farmers market in tow.

Now, Jones and her staff drive two or three routes a day, meeting up to a dozen families on a given route. Families also have the option to pick up their week’s share of produce from their stationary market on Thursdays. Currently, Caja serves 150 households, with 75% of those being families of three or more people.

How food deliveries foster community

For DeBorah Ogiste, 65, of Hendersonville, the produce deliveries have not only relieved the financial burden of feeding her family, but also improved her grandson Elian’s health.

Ogiste’s daughter passed away two months after Ogiste retired. Elian, now 8, has a compromised immune system and, as a result, is particularly sensitive to environmental allergies and asthma. He’s been hospitalized several times due to RSV and breathing issues. “If he catches a cold, it’s always more than a cold,” Ogiste said. Having to take Elian out of school for sickness was a common occurrence — at least once or twice a month.

Food stamps, which covered up to $98 a month, were simply not enough for her and a growing boy. “We were definitely food insecure,” Ogiste said. But since they started receiving deliveries from Caja in spring 2022, Elian has been eating healthier, staying in school for longer, and enjoying the avocado tacos from the food deliveries. Fresh fruits and vegetables help regulate her grandson’s allergies and reactions to environmental triggers.

HOP and Caja have also helped Christal Whitmire, 65, of Hendersonville, to wean off her long list of medications. She has long been diagnosed with degenerative disk diseases, spinal stenosis, and fibromyalgia. At one point, Whitmire said that she was prescribed to take dozens of pills each day for her neural conditions, depression, insomnia, migraines, mood stabilizers, high cholesterol, and beyond.

With access to Caja’s food deliveries, she said she’s lost over 100 pounds. “My whole digestive system is better, and then that helps with my sleep. Then, that helps with my headaches,” she said, which in turn reduces her incidence of seizures.

Recently, Whitmire tossed out her prescription for trazodone, a pill meant to help her sleep.

Beyond the health improvements experienced by many families is a deeper, more emotional benefit of the program: Having someone deliver food to you every single week creates familiarity, trust, and community. Some families list Jones as an emergency contact. The pandemic may have bred loneliness and isolation, but nonprofits like Caja are working to rebuild a community fabric.

“It’s not really [about] the vegetables,” Jones said. “The vegetables open the door to addressing social isolation and community cohesion, which we think are also social determinants of health.”

The limits of the Healthy Opportunities Pilot

Despite the good intentions of the Healthy Opportunities Pilot, some participants still fall through the cracks. For instance, individuals who turn 65 and roll off of Medicaid and onto Medicare will no longer be registered for HOP, as the program currently serves only Medicaid patients. (However, if someone else in their household is enrolled in Medicaid, they remain eligible.) Stradley, HOP’s executive director, said that the program will be able to offer services to patients who are eligible for Medicaid and Medicare as early as 2024.

Peggy Cummins, who recently turned 65, learned this the hard way. She was food insecure and received deliveries from Caja for the last two years. She also registered for housing help through HOP as her living situation was, in her words, “decrepit and rotten.”

“I can see the ground through the siding. A piece of drywall broke. I had a snake in here and rats,” she said. “It’s not fit for humans to live in. But it’s all I’ve got.” She hoped that HOP could help her, but now that she is no longer a registered member because her health insurance changed, “I don’t have any hope.”

Stradley recognizes other challenges and limitations of HOP’s housing program, especially because vacancy rates across the country for affordable housing are so low. In geographical areas where finding new housing is especially challenging, Stradley said that HOP is able to allocate funds to help families improve their current homes.

Jacques, who also expressed a need for housing when her family got enrolled in HOP, had a long-awaited but happy ending to her saga. In July, she finally received a call from a local nonprofit: They found a new, safe place for her and her family to rent.

The transformative power of social health care

Tracking the results of the pilot program could help change health policy in the U.S., especially “if the interventions are shown to improve health and do so in a way that’s cost saving or cost equivalent to other medical interventions,” said Mozzafarian of Tufts University.

“We are aware that many eyes are on us,” said Stradley. “We are working hard to generate the evidence that could persuade other payer groups to invest in social and clinical health care, including Medicare, private payers, and more.”

The Biden administration is also pushing to strengthen Medicaid and the Affordable Care Act. An executive order in January 2021 emphasized that states should utilize waivers like the 1115 that expand Medicaid coverage and access to care.

Jacques, who has seen how a pilot program like HOP can help her family’s physical health and psychological safety, believes that programs like this should eventually become a permanent fixture in our health systems. “Some people get stuck and they don’t know how to get out of whatever the situation may be,” she said. “This program is so important, not just to me, but to many. It’s a lifeline.”

STAT’s coverage of chronic health issues is supported by a grant from Bloomberg Philanthropies. Our financial supporters are not involved in any decisions about our journalism.