In Defense Of SNAP

Written by Jane Jeong, student in the Food Law and Policy Clinic, Fall 2017.

SNAP is already the nation’s “most effective” economic stimulus program.

The political battle over the 2018 Farm Bill is already well underway and—if rhetoric from the Trump Administration is any indication—it won’t be an easy fight.  Threatening to gut $192 billion from SNAP over the next decade, the White House is proposing an unrecognizable overhaul of a program that services the fundamental needs of 42 million Americans every single day.

The Supplemental Nutrition Assistance Program (SNAP) has been called the “most effective” economic stimulus program in the United States.

I will be the first to admit that SNAP is not perfect; no government assistance program is. But it is by far the best option we have as our nation’s first line of defense against hunger. Among all SNAP recipients, approximately half are children and 90 percent are African American. Approximately 75% of SNAP recipients receive benefits for a year or less. It is often the only form of income assistance that struggling households receive from the federal government. SNAP is even considered the federal government’s “most effective” economic stimulus program, boosting the economy by $1.73 for every $1.00 of benefits spent.

Under the current political climate, several proposals have been made to change the nature and scope of SNAP in order to reduce participation rates. Common attacks on the program typically center on its structure as an entitlement program and on scandalizing incidents involving fraud or error. I will address these common attacks in turn.

We should preserve SNAP as an entitlement program, simply because that is the best structure to retain its flexibility in times of unexpected economic need.

As an entitlement program, SNAP is flexible: It currently guarantees benefits to eligible individuals and households who meet a certain set of defined qualifications. This structure allows enrollment to fluctuate quickly in response to changes in economic circumstances at the individual, household, or societal level. By nature, entitlement programs are countercyclical; SNAP enrollment increases during recessions (when more families face the burdens of poverty) and decreases during recoveries (which is what has actually happened since the 2007 financial crisis). The flexibility of SNAP as an entitlement program also allows the program to support communities that are suddenly affected by crisis, such as the water crisis in Flint, Michigan, among other disasters.

Currently, the federal government pays the full cost of SNAP benefits and splits administrative costs with all 50 states that operate the program. In fiscal year 2015, the federal government spent approximately $75 billion on SNAP, of which 93% went directly to households for food purchases. Along with the Trump Administration, Republican budget proposals have consistently proposed converting SNAP into an annual “block grant” disbursement—which would provide a lump sum of funds for each state to administer SNAP on its own—alongside $125 to $192 billion in overall cuts to the program.

Block grant proposals are not unique to SNAP, and it is therefore worth exploring the following reasons most commonly referenced in support of such a structural shift. First, proponents claim that block grants are more efficient than entitlement programs, as they reduce reporting requirements to the federal government and provide local decision-makers more decision-making flexibility.  However, states already have significant discretion in administering SNAP under the current structure—including decisions over statewide eligibility criteria, work requirements, and extent of coordination with other government programs. Furthermore, federal oversight ensures an additional layer of accountability for states to run efficient and transparent processes.

Second, some legislators support block grants because they offer a cheaper alternative. By design, block grants are instruments that decentralize the government and slash federal spending. By allocating a finite budget to a state for a particular program, the federal government effectively can cap its own spending (since the state would be responsible for any additional gaps in funds). But this would be a particularly disastrous result for SNAP recipients living in states with budget shortfalls, since it is not uncommon for states to divert money to fulfill other budgetary gaps under block grant programs.

Such proposed changes in structure make even less sense when considering the overall goal of SNAP: to serve as the nation’s foremost safety net. Inherent in this goal is the need to remain responsive to changes in economic conditions—including sudden job losses and natural disaster relief. Under the current entitlement structure, eligible individuals typically receive benefits within 30 days of applying and, in some emergencies, can receive benefits in as little as seven days. Benefits last only as long as they are needed; recipients must reapply for benefits every 6 to 12 months and report any changes in income or economic circumstances.

Such flexibility has been proven to work. For instance, when unemployment increased 93% during the latest financial crisis from 2007 to 2011, SNAP participation grew by 70% over the same period as more families needed help with food purchases. Once the economy recovered and unemployment rate fell in 2014, SNAP participation and spending began falling with it. This is precisely why SNAP spending as a share of GDP has actually been decreasing and is projected to fall furtheras the economy improves, the Congressional Budget Office projects that the number of participants will fall by 2 to 4 percent each year over the next ten years, from 45.8 million in fiscal year 2015 to 33.1 million by 2026. Such quick responsiveness to real-time need is possible only because of the program’s current entitlement structure, which is essential for SNAP to serve as the nation’s foremost safety net.

SNAP is not a program rife with fraud or waste; in fact, SNAP has one of the lowest error rates among government programs.

Much public opposition to SNAP is the result of unrepresentative but politically powerful anecdotes about over-enrollment, fraud, and abuses in the program. These stories paint SNAP as inefficient or riddled with free-riders who are too lazy to find jobs. The reality, however, is that fraud and error are far less rampant in SNAP than in any other large government program. For instance, improper payment rates for Medicare and Medicaid totaled 10.1% and 8.1%, respectively, in 2013. By contrast, SNAP error rates ranged from 3% to 4% around the same time. These low error rates are likely attributed to SNAP’s quality control program, which is largely considered one of the most rigorous payment error measurement systems of any public benefit program. For instance, when Congress enacted the Improper Payments Act in the early 2000s to reduce improper payments by federal agencies, SNAP was among the few programs that had already met the newly imposed standards.

In addition to low rates of erroneous payments, incidents of household fraud (intentional misrepresentation of eligibility) and underground trafficking (the sale of SNAP benefits for cash) are similarly low and collectively account for an estimated 1.3% of the total food stamp program per year. Trafficking rates have gone down significantly since EBT cards requiring pin numbers were introduced. With these purchase cards, computer programs can easily monitor SNAP transactions for patterns that suggest abuse on behalf of enforcement agencies.

The USDA has reported declines in the rate of trafficking from 4% to 1% of SNAP benefits over the last 15 years as a result of such programs, and the Department has actively taken steps to further improve program integrity—particularly among small- to mid-sized retailers. Although 82% of all benefits are redeemed at larger supermarkets (which have an estimated <1% rate of trafficking), small- and medium-sized retailers account for an estimated 85% of all trafficked redemptions. In response, the USDA has increased data mining and investments in software that track recipients who seek replacement EBT cards frequently and stores that report unusually high EBT sales.

Don’t gut SNAP; strengthen and defend it.

In sum, instead of gutting the program—which would untangle years of progress and, more importantly, leave millions of Americans at much greater risk of poverty—Congress should focus on replicating its success and building on the strides already made in the fight against domestic hunger. The 2018 Farm Bill is a real opportunity to build on the progress SNAP has already made for millions of Americans facing unemployment and poverty, and defending our nation’s best safety net is simply the best way forward against the backdrop of current economic realities and realistic nutritional needs.


D-SNAP Modernization: Simple Reforms To Help The Most Vulnerable

Written by Tammuz Huberman, student in the Food Law and Policy Clinic, Fall 2017.

Months after Hurricane Irma, thousands of people are lining up in Miami to sign up for Disaster Supplemental Nutrition Assistance Program benefits, or D-SNAP. More than 30,000 people registered for D-SNAP in Florida after just a few days of program registration opening, making modernization efforts more timely than ever.

D-SNAP provides food assistance to low-income households with food loss or damage caused by natural disasters. The USDA’s Food and Nutrition Service approves D-SNAP benefits for disaster areas that, like SNAP, are administered by states and through Electronic Benefits Transfer (EBT) cards to individuals.

Notably, D-SNAP benefits are available to individuals who were not receiving SNAP benefits prior to a natural disaster. Individuals may qualify for D-SNAP if they are experiencing disaster-related expenses in the immediate aftermath of a disaster such as housing-related expenses such as evacuation or temporary relocation or shelter expenses, personal injuries, or loss of income. Individuals already participating in SNAP are sometimes eligible to receive additional temporary benefits under D-SNAP.

The wave of recent natural disasters—Hurricanes Maria, Irma, and Harvey and the Western wildfires—has prompted a number of D-SNAP or other USDA food-emergency responses:

These temporary benefits are critical to ensuring the food security of disaster-affected individuals and families. However, the recent magnitude of demand for government assistance with respect to food has highlighted some administrative and technological weaknesses of food assistance in the wake of natural disasters.

In Florida, thousands of people are waiting in lines for hours to register for D-SNAP, raising safety concerns, especially with respect to high temperatures and heat exhaustion and accessibility issues for individuals with disabilities. Technological hiccups further exacerbate wait times and D-SNAP administrability.

When demand for emergency food assistance overwhelms agency capabilities, those seeking assistance should not be the ones who suffer. Rather than spending their time on line to secure their family’s next meal, these individuals should be rebuilding their lives. Before the next inevitable natural disaster hits, Congress and USDA should consider a few easy changes to improve program administration.

First, online registration would mitigate crowd control issues (including traffic issues in reaching D-SNAP registration hubs), help anticipate demand (and therefore provide for adequate funding, sufficient number of personnel, etc.) and streamline administrability. Another solution is pre-approving all individuals in disaster-affected zip codes for D-SNAP. After all, natural disasters don’t discriminate based on income, but by geography.

While in-person and individualized registration is touted as an anti-fraud mechanism, other disaster assistance programs such as FEMA primarily rely on online methods that avoid the time-consuming, unsafe and expensive D-SNAP methods. Some states, including Florida, already have pre-registration options for D-SNAP. Taking this one step further and fully migrating to online registration or geographic pre-approval are 21st century solutions to improve upon the necessary and important relief emergency disaster food assistance provides.


Employment And Training Vital For SNAP Participants

Written by  Imani Tisdale, student in the Fall 2017 Food Law and Policy Clinic.

Oklahoman Bryan Parker is one of the 42 million Americans served by the Supplemental Nutrition Assistance Program, or “SNAP.” He is also a perfect example of why Congress should renew and expand their investment in Employment and Training (“E&T”) programs as part of the coming farm bill reauthorization.

Parker is a 51-year-old veteran and has always been a hard worker. In his testimony before the Senate Agriculture, Nutrition and Forestry Committee, Parker explained that there was a time in his life when he did not worry at all about paying bills or when he would have his next meal. After his time in the military, he ran a small business in Japan for more than 20 years and then returned to his hometown of Tulsa, Oklahoma, where he lived a stable life.

Like millions of SNAP recipients, that stability ended abruptly when Parker lost his job. Even though he continued applying to new positions, the loss of his job and inability to get a new one led Parker to develop anxiety and depression. Still trying to maintain his life without the aid of others, he sold his car and eventually his house.  After moving into a cheap motel, he faced daily struggles from the realities of unemployment. As Parker told the Committee, “A man can endure a lot of pain and suffering, but the one thing that is impossible to ignore is hunger.”

Parker has become an ABAWD, or “able-bodied adult without dependents,” who needs SNAP assistance. This category of SNAP participants has been the target of many attacks on SNAP, the most popular argument being that these recipients are “lazy” and “freeloaders.” However, Parker’s story is just one of many that prove how wrong these misconceptions are. Parker was completely self sufficient until he fell down on his luck. In order to change the circumstances of SNAP participants like Parker the federal government has created, and should continue to invest in, employment and training programs.

The Supplemental Nutrition Assistance Program Employment and Training Program (SNAP E&T), was created to help SNAP participants enter the work force or achieve higher paying jobs within it. Studies have found that without outside intervention, many working poor will remain in jobs that pay below the poverty level. SNAP E&T seeks to intervene. Amongst other things, SNAP E&T programs provide vocational skills training and certifications, work readiness training and post-employment services.

Bryan Parker is presently enrolled in a job training program similar to those provided by SNAP E&T. The 16-week culinary trade program teaches students advanced culinary techniques, nutrition, and professionalism in the workplace. The program also provides graduates with a Food Safety Manager Certificate and assistance with finding full-time employment. While Parker’s job training is not a SNAP E&T program, it demonstrates the effectiveness of employment programs. The job training program provided to Parker will equip him with the skills necessary to build a lasting career and that will make it possible for Parker to one day no longer need SNAP benefits.

Additionally, as he explained to the Committee, thanks to SNAP and the job training program Parker is now optimistic about the future. He dreams of one day opening a food truck that will become popular enough to grow into a brick and mortar restaurant. As Parker’s story shows, job training programs do not simply provide someone with the skills necessary to find a job, but can change his or her outlook on life. In this way, his story serves as a reminder of why employment and training programs should be supported and further developed.


Colorado lifts Medicaid restrictions for treating hepatitis C

Originally published by STAT on December 4, 2017. Written by Ed Silverman.

Amid ongoing criticism that some states continue to curb access to hepatitis C drugs, Colorado officials have lifted restrictions that determined when patients could receive treatment. Going forward, Medicaid beneficiaries will no longer have to demonstrate an advanced stage of liver disease to be treated.

In explaining their decision, state officials pointed to declining costs for the medicines, which have dropped in price recently as more new drugs become available. Over the summer, AbbVie (ABBV) introduced a treatment that costs $26,400, before rebates and discounts, for an eight-week regimen, which is significantly less than the $84,000 that Gilead Sciences (GILD) charged for 12 weeks of treatment for Sovaldi when it was first marketed four years ago.

“Over the past two years, there are more choices among these drugs, which has driven their cost down substantially,” said Dr. Judy Zerzan, the chief medical officer at the Colorado Department of Health Care Policy and Financing, in a statement issued on Friday. The department reportedly spent nearly $27 million treating 326 hepatitis C patients last year, or about $82,000 per person.

The move also comes a year after the American Civil Liberties Union and Center for Health Law and Policy Innovation at Harvard Law School filed a lawsuit accusing the state Medicaid program of “illegally” providing the medicines only to people with the most advanced stages of liver disease, such as cirrhosis. The state was also accused of violating standard medical care and disregarding federal warnings.

“Were a cure for cancer … discovered, no one would tolerate insurance providers telling patients: ‘We need to wait until you get really sick before we treat you.’ But that’s what patients in Colorado with hepatitis C were being told, and what patients in other states are still being told,” said Kevin Costello, the litigation director at CHLPI, in his own statement. “It’s unconscionable.”

The new generation of hepatitis C medicines, which first became available in early 2014, offered cure rates exceeding 90 percent and fewer side effects than less effective drugs that had been the standard of care. This quickly prompted many physicians to write prescriptions, even though the initial price for Sovaldi—and for subsequent medicines—was a budget buster for many private and public payers.

Drug makers and their supporters, however, argued that near-term spending would save money down the road on treating liver failure or liver cancer, and on liver transplants. But many state Medicaid programs responded by instituting coverage restrictions, despite warnings from the Centers for Medicare and Medicaid Services in 2015 not to do so because such moves may run afoul of the law.

Placing restrictions may be “contrary to the statutory requirements” of a federal law that requires state Medicaid programs to pay for all medically necessary treatments, CMS officials wrote in their notice to the state programs. And the agency warned state officials to monitor managed care organizations, which run Medicaid programs, to ensure they provide patient access to the medicines.

At the same time, the American Association for the Study for Liver Diseases and the Infectious Diseases Society of America issued guidelines that counseled physicians to “treat all patients as promptly as feasible.” However, the groups acknowledged that physicians may have to take into account the cost of the hepatitis C medicines when deciding whom to treat first.

recent analysis by the CHLPI found that, over the past three years, state Medicaid programs have, in fact, done a much better job of disclosing information about access to hepatitis C medicines and fewer are restricting treatment to patients. Nonetheless, over 65 percent of states continue to have liver disease restrictions, and nearly one in four states still require patients to have advanced liver disease before treatment.

The move by Colorado officials will not automatically end the lawsuit, though. It’s “definitely a major step forward,” Mark Silverstein, legal director at the ACLU in Colorado, wrote us. But “since there’s now a class certified by the court, it’s not resolved just by getting coverage for our individual plaintiffs. For one thing, we need to make sure that everyone in the class gets notice that they are now eligible.”

Massachusetts Food is Medicine State Plan Planning Council Serves Up Official Launch to Expand Nutrition Interventions for Vulnerable Populations Across the Commonwealth

Written by Emily J. Wilson, MPH, MS, CHES, Health Professions Education Doctoral (HPED) Program, Simmons College; CHLPI Consultant 

On October 30th, the Massachusetts Food is Medicine State Plan Planning Council kicked off the official launch of its work to help reduce the cost of care, expand access to nutrition, and improve health among vulnerable populations by advancing the Massachusetts Food is Medicine (FIM) State Plan.

The FIM State Plan Project is led by the Center for Health Law & Policy Innovation (CHLPI) of Harvard Law School and Community Servings, a non-profit leader in nutritional healing. The Project seeks to accomplish several critical goals over the next year in order to move the FIM work forward, which include:

  1. Identifying areas of need for FIM services;
  2. Assessing access to FIM services in Massachusetts;
  3. Publishing a report on the status of FIM need, access, and recommendations for FIM expansion.

To accomplish these goals, FIM Project leaders are embarking upon a multi-pronged approach to engage stakeholders, gather high-quality data, and develop a blueprint for concrete policy solutions. This blueprint will be adopted as the Massachusetts Food is Medicine State Plan and used to scale up FIM services throughout the Commonwealth.

Key knowledge, insights, and advisement to the Project are provided by the Massachusetts Food is Medicine State Plan Planning Council; a diverse, interprofessional coalition of health care providers, community-based agencies, insurers, and professional, academic, and policy organizations. The Council’s membership includes representatives from across the distinct geographic regions of Massachusetts. These members steward dozens of local and statewide organizations and provide interdisciplinary activities in health policy, research, clinical practice, human services, and community action. During the inaugural meeting, members convened for the first time to discuss strategies and identify steps for operationalizing this year’s FIM goals.

After the kick-off meeting, several Planning Council members presented at the 5th Annual Food is Medicine Symposium, held at Wasserstein Hall on Harvard Law School’s campus. Both Dr. Kathryn Brodowski, Senior Director of Health & Research at the Greater Boston Food Bank, and Sue Joss, CEO of Brockton Neighborhood Health Center, emphasized in their talks the vital importance of relationships among health care providers, communities, and businesses to address nutritional needs. Browdowski cited innovative clinical partnerships to achieve better patient outcomes, while Joss highlighted the advancements her clinic has made since co-locating with Vincente’s local family-owned grocery, which provides culturally and socially competent food products and services to residents.

For updates on the Massachusetts Food is Medicine State Plan and opportunities to provide feedback, visit the FIM State Plan page on CHLPI’s website, check back here for updates on our blog, and sign up for the FIM State Plan email list here or by contacting Katie Garfield, Staff Attorney and Planning Council Co-Leader, at


The Hidden Health Crisis of the Opioid Epidemic

Originally published by Reuters on December 7, 2017. Written by Robert Greenwald, faculty director of the Center for Health Law and Policy Innovation of Harvard Law School and Ryan Clary, executive director of the National Viral Hepatitis Roundtable.

The American epidemic of opioid abuse is finally getting the attention it warrants. While policy solutions continue to be inadequate, the decision by President Trump to declare a national opioid emergency has helped to increase discussion about the problem and how the country can solve it. But the conversation also needs to address a dangerous—and largely ignored—interconnected public health crisis wreaking havoc among young Americans.

The problem is that more Americans than ever are injecting opioids and inadvertently infecting themselves with hepatitis C. Shared needles mean shared blood-borne infections—and that’s how the opioid crisis has created a new generation of hepatitis C patients. The number of reported hepatitis C infections nearly tripled from 2010 to 2015, with the virus is spreading at an unprecedented rate among young people under 30—who are now, for the first time, the most at-risk population for contracting and transmitting hepatitis C.

In the United States, an estimated 3.5 million people, and likely more, are currently living with hepatitis C. The virus kills nearly 20,000 Americans each year—more than HIV and all other infectious diseases combined.

Hepatitis C attacks the liver, causing cirrhosis—or scarring of the liver—and leads to severe liver damage, liver cancer and liver failure. The virus is the leading cause of liver cancer—the fastest-growing cause of cancer mortality in the U.S., which kills twice as many Americans now than it did in the 1980s. Driven by young people who inject drugs, new cases of liver disease have nearly tripled nationwide in just a few years.

Fortunately, we now have an unprecedented chance to eliminate the virus. More and more treatments are available that provide cure rates of over 95 percent, without the debilitating side-effects of older and far less effective hepatitis C therapies. These newer treatments, known as direct-acting antivirals, eliminate the hepatitis C virus from the body, stopping the virus’ attack on the liver and preventing the patient from infecting others.

While some of these treatments made national headlines for their initial $1,000-a-pill sticker prices, that time has passed. Due to increased competition as new treatment options have entered the market over the last three years, the cost of a cure has dropped dramatically. The price will decrease even further as additional alternative cures are approved.

For too many Americans, however, barriers to getting cured remain. While access has increased significantly for the more than 216 million Americans with private insurance and the 53 million who have Medicare, state Medicaid programs are a different story. The more than 70 million low-income Americans covered by Medicaid, including low-income adults, children, pregnant women, seniors, and people with disabilities, continue to face severely limited access to cures for hepatitis C.

Negotiated discounts to Medicaid are proprietary and confidential, but we know that the price to Medicaid for leading hepatitis C medications is now in the $20,000-$30,000 range—far less than the cost of treating the liver damage and cancer caused by hepatitis C. Each year, hepatitis C-positive patients average more than five times the hospitalizations and more than three times the number of emergency room visits as patients without the virus. Hepatitis C is also the underlying cause of approximately 30 percent of all liver transplants performed in the U.S. — an operation which costs an estimated $577,000 and thousands more to maintain ongoing health.

But it’s not just about the cost-effectiveness of the cure. Medicaid is America’s safety-net health care program for low-income individuals, and it is required by law to provide access to medically necessary treatments. As an entitlement program, there is no such thing as a waiting list or set budget in Medicaid. The program is specifically designed to shrink and expand to respond to public health needs, disease outbreaks and treatment advances.

It’s time that all state Medicaid programs start treating hepatitis C as the public health threat that it is, but that’s not what is happening in most states.

In our new report, Hepatitis C: State of Medicaid Access, we graded all 50 state Medicaid programs, as well as the District of Columbia and Puerto Rico, according to access to hepatitis C cures. More than half of Medicaid programs received a “D” or an “F” for withholding a cure based on restrictions related to liver disease progression, sobriety requirements, and limitations on who can prescribe the treatments.

All of these restrictions contradict established treatment recommendationsfrom the American Association for the Study of Liver Diseases and Infectious Disease Society of America. They also run afoul of guidance from the Centers for Medicare & Medicaid Services, which states clearly that some states are limiting access to hepatitis C treatment in violation of federal Medicaid law. The guidance to states puts Medicaid programs on notice that they must comply with the requirement to provide medically necessary treatments, and this obligation has been confirmed by U.S. Federal District Court decisions.

Not only are these restrictions imprudent from a public health, cost-savings, and moral perspective, but they are medically unfounded. A growing body of research shows that drug-users can be cured just as easily as people who don’t use drugs—and that curing the virus in substance users can lead to low re-infection rates.

Current restrictions do nothing but needlessly jeopardize the health and wellbeing of hepatitis C patients and the general public. With opioid addiction at an all-time high, there is no justification for prohibiting drug users—the population most likely to spread this highly communicable disease—from accessing a cure.

States that are still rationing a cure based on outdated cost concerns and imaginary medical concerns are not only allowing the hepatitis C epidemic to spread, they’re exacerbating the lasting aftermath of the opioid crisis. It’s time for them to look at the bigger picture.

The State of Food Innovation: Food Waste and Recovery in Boston

Originally written and published by BranchFood.

Maybe mom was right: we should be finishing more of our plates.

The statistics on how much food Americans waste are staggering:

  • Collectively, we waste around 40 percent of our food supply;
  • On average, every American wastes 400 pounds of food per year;
  • The cost of this wasted food is $218 billion, or 1.3 percent of the U.S. gross domestic product.

Food waste is obviously an equity issue. Feeding the world gets more difficult each year, as the population explodes (expected to top 9 billion by 2050) and the extreme weather associated with climate change threaten crop yields in developing countries year over year. Even as we write this, Yemen is on the verge of famine, with 3.2 million children and adults at imminent risk of starving.

But as we can see from the data above, food waste is an economic issue as well. Wasting less of the food produced in the United States would allow more of it to benefit needy families—reducing the financial strains on our social safety net. And from the standpoint of corporate efficiency, millions of American restaurants and food retailers essentially take a sledge hammer to their bottom lines allowing more than 25 tons of food to end up in the landfill each year—costing them $57 billion annually—according to the 2016 ReFed report on food waste.

It appears this issue has finally caught the attention of lawmakers, business leaders, and investors. In fact, food waste reduction is one of the most promising areas for innovation and investment, with ReFed estimating that reducing food waste by 20 percent over the next decade will require an $18 billion investment from the public, private, and non-profit sectors. On the government end, the Commonwealth of Massachusetts has emerged as a leader in curbing food waste, enacting in 2014 a law requiring Bay State businesses and institutions that discard more than a ton of organic matter per week to recycle, compost, or reuse it instead of sending it to a landfill.

Innovative Nonprofits Lead the Way

As has been the case with many other social problems, nonprofit organizations have pioneered innovative solutions to rescue food that would otherwise be headed to landfills. Founded in 2010, Lovin’ Spoonfuls has rescued more than 7.5 million pounds of excess fresh food from grocery stores, farmer’s markets, restaurants, and wholesalers, delivering it to social service agencies and meal programs that serve those in need. Boston Area Gleaners operates under a similar model, harvesting surplus farm crops and donating them to food pantries and meal programs. Cambridge-based Food for Free is something of a hybrid of the first two, serving Boston’s Pine Street Inn with fresh food grown on their farm in Lincoln, while also picking up discarded food and delivering it to communities throughout Eastern Massachusetts. Community Servings utilizes rescued ingredients—much of it donated by farms or other producers—in many of the chef-made meals it prepares for its chronically and critically ill clients.

Finally, a nonprofit grocery store that sells only surplus foods, produce gleaned from local farms, and packaged foods that are near or at their sell-by date. Founded by former Trader Joe’s President-turned-food rescue aficionado Doug Rauch, The Daily Table has thrived at its Washington Street location in Dorchester since 2015, and a second location is currently under construction in Roxbury—set to open sometime in 2018.

Purpose and Profits

These nonprofits play a critical role in both reducing waste and alleviating food insecurity, but a growing number of local entrepreneurs have discovered that having a social purpose doesn’t have to mean not making a profit. With ReFed’s estimates that an $18 billion investment will be necessary to curb food waste over the next decade, private investment is not only needed—it’s a smart business decision.

“In many ways, food waste is an emerging industry, just like recycling was in the 1980s, or renewable energy in the early 2000s,” says Chris Cochran, executive director of ReFed.

Several area startups have worked into their business models solutions for curbing food waste that are great for the planet, great for hungry families, and great for their investors. With a $2.5 million investment from the Fink Family Foundation behind them, Spoiler Alert is expanding its enterprise software that lets restaurants, farms, and manufacturers set up secondary markets for food that would normally be thrown away. It recently partnered up with distributor Sysco, which rakes in $50 billion annually, to begin diverting excess food, for sale or donation, from the dumpster to anti-hunger nonprofits and community groups.

For restaurants and households who’ve found composting to be difficult in the past, Boston-based Bootstrap Compost lessens that burden. Restaurants or households simply fill up one of Bootstrap’s five-gallon buckets with food scraps and leave it outside for one of the business’s drivers to pick up. Bootstrap processes the scraps and, in return, returns fresh composted soil to the customer.

Getting its start in 2008, Waltham-based Harvest was one of the earliest businesses turning discarded organic materials into soils, fertilizers, and clean energy. The anaerobic digester Harvest developed is being utilized by municipalities and large corporations around the world, like the City of Vancouver and Disney World, earning it a spot on the Global CleanTech 100 list. Globally, the anaerobic digestion market, which is at the forefront of smarter large-scale organic waste management, saw around $6.25 million in expenditures and investment in 2016.

Kickstarter-funded Food for All designed a mobile app that allows consumers to purchase, at deep discounts, unsold restaurant meals at the end of the day—with a few touches of their smart phones.

Lazy Bear Tea, founded in Cambridge, has developed its product around a commonly discarded byproduct of the coffee bean. Its bottled iced teas are all made from the cascara, the fruit of the coffee cherry, which typically contributes to 2.25 tons of waste every year and 75 percent of the water pollution associated with coffee production.

Funding the Zero-waste Vision

Fortunately, mission-driven founders are not out on their own in this brave new world of food waste reduction. Plenty of investors—several of which call Greater Boston home— view food rescue and green waste management as wise sectors in which to put their money.

Cambridge-based Fresh Source Capital has made rebuilding local food and agriculture systems the cornerstone of its investments—including food waste reduction. It has pumped funding into Cambridge-born Spoiler Alert, as well as California-based Imperfect Produce—a home and office delivery service that specializes in “ugly” fruits and vegetables that are typically discarded on farms.

Anterra Capital, based in Boston and Amsterdam, invested in Food Freshness Technology, which developed It’s Fresh!: a filter for produce packaging that extends the life of fruits and vegetables and reduces waste throughout the supply chain.

If MissionPoint Partners (which has an office in Boston) has its way, expect the number of investors entering the food waste reduction sector to increase dramatically in the coming years. In 2015, MissionPoint co-launched its ReFed campaign with a goal of educating investors on the issue of food waste and galvanizing $300 million in annual philanthropic giving and impact investment for food waste reduction. More than 30 businesses, foundations, and government leaders came up with 27 cost-effective, scalable solutions to reduce food waste by 20 percent in the next 10 years.

A Waste-Free Future

Curbing food waste is a “triple-bottom-line investment”—benefitting people, healing the planet, and driving economic growth and profits—says Emily Broad Leib, assistant clinical professor at Harvard Law School and founder of the Harvard Food Law and Policy Clinic. Over the last several years, Broad Leib has emerged as a thought leader in strategies for reducing food waste, working with governments and institutions to enact waste reduction policies.

A promising frontier in this movement—one that is largely being led by Broad Lieb and the clinic she directs—is that of reforming date labels on packaged foods. The federal government currently provides no standards regulating such labels, which Broad Leib says rarely refer to a product’s freshness or quality and lead retailers and consumers to discard perfectly edible food. The FLPC has run a campaign to bring awareness to the date labeling issue, and in February 2017, the two main food industry trade groups—Food Marketing Institute and the Grocery Manufacturers Association—announced a voluntary initiative to standardize date labels on consumer-facing packaged foods by the Summer of 2018.

Clearly, the Bay State is fertile soil for public, private, and nonprofit efforts to reduce food waste—which should make all of our mothers very happy.


Colorado Lifts Restrictions for Treating Hepatitis C Patients; No Longer Need to Have Advanced Liver Damage to Receive Drugs

Originally published by the Denver Post on December 1, 2017. Written by Jennifer Brown.

Colorado soon will begin treating needy hepatitis C patients with the latest antiviral drugs instead of waiting until they are sick enough to qualify.

Friday’s decision by the state Medicaid department comes in the midst of a class-action lawsuit filed by the American Civil Liberties Union of Colorado and after top health officials asked the department to lift restrictions that determined which patients could receive life-altering treatment.

It also comes as the price of the antiviral drugs—which cure up to 90 percent of patients—has dropped from $84,000 per treatment to about $14,000.

Colorado’s previous policy, which required Medicaid recipients with the virus to have advanced liver damage in order to receive treatment, was “unconscionable,” said Kevin Costello with Harvard Law School’s Center for Health Law and Policy Innovation, a partner in ACLU’s suit.

“Were a cure for cancer to be discovered, no one would tolerate insurance providers telling patients: ‘We need to wait until you get really sick before we treat you,’” he said in a statement after Colorado’s announcement.

Until about two years ago, the best treatment for hepatitis C included year-long, toxic injections with often-miserable side-effects and an estimated cure rate of only 50 percent. The latest antivirals, pills taken for as few as eight weeks, come with few side-effects and a 90 percent cure rate.

Because of the price drop, the state Medicaid department expects to spend the same yearly amount on treatment but treat about 20 percent more patients. Other states that lifted restrictions treated 5 to 50 percent more people, said Dr. Judy Zerzan, chief medical director for the Colorado Department of Health Care Policy and Financing.

Department officials said budget figures showing how much the Medicaid department spent last year treating patients with hepatitis C were unavailable Friday. Zerzan said in 2016 that the department spent $26.6 million treating 326 hepatitis C patients—an average cost of $82,000 per person.

Friday’s policy change, she said, was “part of our usual process (in) keeping up with the pace of change and the evidence” and not related to the lawsuit. The new rules take effect Jan. 1.

Among those who asked the Medicaid department to change policy was Denver Public Health director Bill Burman. In a letter to the department last year, Burman wrote that the drug restrictions were leading to more health disparity and death at Denver Health, the largest health care provider for low-income people in Denver.

In addition, the federal Centers for Medicare and Medicaid warned states against imposing “unreasonable” restrictions of the antiviral drugs. Medical associations have recommended the treatment for all people with hepatitis C, not just those in the later stages of liver scarring.

Dr. Sarah Rowan, associate director of HIV and viral hepatitis prevention at Denver Public Health, said she was thrilled to learn of the new policy while in Spain for World AIDS Day. “This marks a critical turning point in the epidemic,” she said via email.

The lawsuit against the Medicaid department is pending. Because the suit is a class-action one, a judge, not the attorneys, must determine whether to dismiss it.

ACLU of Colorado legal director Mark Silverstein called the policy change “a major step forward” to resolving the lawsuit and a “more fiscally sound path” for the state because patients will receive treatment before they have suffered serious liver damage.

Senate Set to Resume Tax Bill Debate with Health Care Components Uncertain

Originally published on on December 1, 2017. Written by  Janel Miller.

The Senate will debate and may vote on the Republican tax reform proposal today, with several critical health care components still undefined, possibly affecting millions of people and billions of dollars.

“The current draft of the Senate bill would repeal the individual mandate, which requires most Americans to obtain health insurance that meets minimum standards,” Pari Mody, associate of Arnold & Porter Kaye Scholer LLP, told Healio Family Medicine in an interview.

Robert Greenwald, faculty director of the Center for Health Law and Policy Innovation, told Healio Family Medicine that stripping mandatory coverage would allow younger and healthier enrollees to forgo insurance which would result in only patients with serious health needs buying plans through the Marketplace and thus, increase the unaffordability of these plans.

“This would bring us back to the pre-ACA days when far too many people could not afford coverage, and ultimately could not get the care and treatment they needed to stay healthy,” he said.

Additionally, healthier patients may become victims of “junk plans” which may cost less upfront, but may cost more in the long-term and do not cover essential health benefits, he added.

The Congressional Budget Office (CBO) said such a repeal would increase the number of uninsured people to 13 million in 2027, raise average premiums in the nongroup market by about 10% in “most years of the decade” and reduce federal deficits by about $338 billion from 2018 to 2027.

In addition, the New York Times reported that the proposed tax plan would add $1 trillion to the federal deficit, contradicting the Republicans’ claim that the tax bill would allow the economy to grow enough to offset the cost of the plan.

Overnight developments

“Last night’s vote was delayed when the Senate Parliamentarian ruled that the proposed ‘trigger’ — to raise government revenues if the Senate tax bill does not achieve the necessary economic growth to offset its costs — would violate Senate reconciliation rules,”

Sebastien Lassuer, a policy specialist at Arnold & Porter Kaye Scholer LLP, told Healio Family Medicine. He added that this trigger would be conflict with the so-called Byrd rule, which prohibits items that do not have a direct budgetary impact. Lassuer also said reports indicate that several Senators, including Senator Bob Corker (R-Tenn.) are now asking for the plan to contain a $350 billion tax increase 6 years into the budget window. “It is unclear whether Republicans will return to the parliamentarian with another trigger that does not violate the Byrd rule or a different plan altogether to gain the support of Sen Corker and other deficit hawks,” Lassuer said.

Current status of votes

As reported in The Washington Post, if three Senators vote no, the tax bill will be defeated. The newspaper cited a “handful” of lawmakers that remained “uncertain or undeclared” as of early yesterday afternoon. That newspaper also reported that Senator John McCain (R-Ariz.), said he would support the tax bill. It was he, Lisa Murkowski, (R-Alaska) and Susan Collins (R-Maine) that cast the votes earlier this year against the so-called ‘skinny repeal’, an attempt to repeal and replace the Affordable Care Act.

Mody told Healio Family Medicine that since then, Collins reached a deal to have two bills — the Lower Premiums through Reinsurance Act of 2017, which would provide states with federal grants to create invisible reinsurance programs and high-risk pools; and the Bipartisan Health Care Stabilization Act, which would temporarily fund federal cost-sharing reduction payments that assist in paying back insurers that must offer cost-sharing subsidies to certain low-income marketplace enrollees — signed into law before the conference report on the tax reform bill is enacted.

Trump said he would support these two bills, Mody said, noting that the CBO estimated the interaction between passing the Bipartisan Health Care Stabilization Act and individual mandate measures would be “small” and adding that the Bipartisan Health Care Stabilization Act would do “little to blunt the impact on the individual mandate repeal.”

Orphan drugs, medical expenses

Mody also noted the current Senate bill lowers the orphan drug tax credit from 50% to 27.5% and eliminates a restriction that would “limit qualified clinical testing expenses to the extent that such expenses were related to a drug which was previously approved by FDA for use in the treatment of any other disease or condition, if all such diseases or conditions in the aggregate affect more than 200,000 persons in the United States.”

“Given that the limitation on the orphan drug tax credit is expected to save $29.9 billion over 10 years, I expect leadership to resist removing this provision entirely,” Mody said, adding that that the House version of the tax bill passed on Nov. 16 eliminated the orphan drug tax credit completely. The House bill also repeals the medical expense deduction that allows individuals to deduct medical and dental expenses that surpass 10% of their adjusted gross income, but the Senate version does not, according to Mody. “Repeal of this deduction could have major implications for individuals and families with extremely high health care costs, including long-term and nursing care, major surgery, and expenses related to chronic disease,” she said. “Assuming Senate passage, this difference between the House and Senate bills would be resolved during conference.”

Patients with chronic illnesses and disabilities are most likely to be negatively impacted by the repeal of the medical tax deduction, Greenwald added.

“As insurance plans are pushing more and more out-of-pocket costs onto enrollees, those who need to use their health insurance are facing higher financial burdens,” Greenwald said. “The medical tax helps soften the blow when costs are particularly high.

“Consider a patient undergoing some of the most expensive therapy for cancer or a chronic illness; this person will no longer be able to deduct extremely high medical expenses incurred to keep them alive and healthy. We live in a country where medical bankruptcy is a very real possibility for many of our citizens, and what’s being proposed now will only exacerbate this problem.”

Effect on Medicaid, Medicare

“There are potentially significant implications on mandatory federal health care spending, which could affect Medicare but not Medicaid,” Lassuer said. “Under the current bill, statutory PAYGO — which provides for an across-the-board sequester of non-exempt mandatory spending programs if Congress enacts net deficit-increasing legislation over the course of the year — would be violated, triggering a sequester that must be carried out by the Office of Management and Budget. This would occur unless PAYGO is waived, a maneuver that would require Democratic votes. At this point it is unclear what Democrats will do, but Republicans are assuming they will waive the rule.

“Medicaid is exempt from this PAYGO-trigger sequestration as well as Social Security. This means that the sequester will not lead to Medicaid cuts. Medicare, however, is subject to the statutory PAYGO sequester but cuts are limited to 4%.”

ACP, AARP urge ‘no’ vote

The American College of Physicians sent the Senate a letter urging these lawmakers to vote no on the tax bill.

“The College strongly believes that tax cuts and other initiatives should not come at the cost of automatic cuts to programs that serve individual and public health, including Medicare, Medicaid, the [CDC] and other agencies,” Jack Ende, MD, MACP, and ACP president, said in a statement.

“Rather than continuing the effort to repeal current-law coverage under the ACA through budget reconciliation measures, or otherwise, we urge Congress to work together in a bipartisan manner to improve coverage and lower costs,” he continued. “Repealing the individual insurance mandate, as part of this legislation or any other, would only result in harm to our patients as would any cuts to Medicare or other vital health programs.”

The American Association of Retired Persons also sent a letter to the Senate, expressing concern regarding the tax bill’s short- and long-term financial impact. “The Tax Cuts and Jobs Act will increase the deficit by approximately $1.5 trillion over the next ten years, and an unknown amount beyond 2027. The large increase in the deficit will inevitably lead to calls for greater spending cuts, which are likely to include dramatic cuts to Medicare, Medicaid, and other important programs serving older Americans,” AARP CEO Jo Ann C. Jenkins wrote. “Unless Congress takes action, the reconciliation legislation will result in automatic federal funding cuts of $136 billion in fiscal year 2018, $25 billion of which must come from Medicare. Such sweeping cuts would be detrimental to an already vulnerable population.”

Informed Imbibing: Closing the Regulatory Gap in Nutrition and Ingredient Information Labeling for Alcoholic Beverages

Written by Tammuz Huberman, student in the Food Law and Policy Clinic, Fall 2017

Let’s say you’re a health-conscious consumer at the grocery store deciding on a beverage to purchase. Maybe you glance at the familiar “Nutrition Fact” panels on food and beverage packages to help you decide what to buy. Bottled water displays zero calories, a can of Coke shows 150 calories, and the average protein shake about 250 calories. Wine? Beer? You’re out of luck: most alcoholic beverages are not required to display nutrition or ingredient information. This makes them virtually the only ingestible consumer products not required to disclose comprehensive product identity or quality information.

While the Food and Drug Administration (FDA) instated mandatory labeling rules requiring use of a standard Nutrition Facts Panel and ingredient list, among other things, following the passage of the National Labeling and Education Act of 1990, alcohol is strangely regulated by a different agency – the Department of Treasury’s Alcohol and Tobacco Tax and Trade Bureau (TTB). TTB oversight of alcohol traces back to the Federal Alcohol Administration Act, passed by Congress in 1935 following the end of the Prohibition Era. Recognizing the tax revenue potential of alcoholic beverages, Congress assigned their regulation to the Treasury Department rather than the FDA. TTB has not adopted a comprehensive labeling regime akin to the FDA’s; as a result, alcoholic beverages fail to provide much in the way of product identity or quality information beyond alcohol content disclosures.

There is a simple fix for this regulatory gap: TTB should require alcoholic beverages to display nutritional and ingredient information in a simplified version of a fact panel, akin to “Nutrition Facts.” This isn’t a tall order: TTB has undertaken approximately six rulemaking and comment periods on the matter since the 1970s; in the most recent proposed rulemaking in 2007, TTB came around to the wisdom of comprehensive labeling and proposed a required comprehensive labeling regime for alcoholic beverages. In fact, the model TTB proposed in 2007 was pretty sensible and reflected reasonable compromise for both industry and consumer advocacy groups. With the brunt of the legwork of a final rule completed, the reason for the 10-year delay in issuing a final rule is not clear—though TTB has suggested it is still in the process of reviewing public comments submitted in 2007.

Recent FDA developments make the present a great opportunity for TTB to act. In 2016, the FDA updated Nutrition Facts with substantive and design changes to ensure consumers are provided with scientifically updated and relevant information in an easily accessible format. TTB should follow the FDA’s lead and issue a final rule for mandatory comprehensive “Alcohol Facts” labels to assist consumers in making complementary and fully informed food and beverage choices. TTB’s label should be mandatory for all alcoholic beverages under TTB oversight, uniform with respect to design, and include reference serving sizes, servings per container, calories, alcohol content, a moderate drinking statement, and ingredient disclosures.  

People should not have to guess the health implications of what they put into their bodies. This is an unequivocal norm when it comes to food. Alcohol should be treated no differently given America’s well-documented obesity crisis and research that firmly establishes the addictive and dangerous qualities of alcohol. TTB has an opportunity to correct a regulatory gap in food and beverage labeling, utilize a powerful and proven public health tool, and empower consumers by helping close information asymmetries with respect to ingestible consumer products.


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