Food insecurity (FI), already common in the United States, was further exacerbated by the coronavirus disease 2019 (COVID-19) pandemic through individual and structural-level pathways. Childhood FI is associated with adverse health outcomes, including increased rates of hospitalization, anxiety and aggression, and poorer overall health.1–3 By taking an active role in addressing FI, children’s hospitals can be a key partner in meeting the needs of their communities and promoting health equity. There is growing evidence supporting the feasibility and acceptability of health care-based programs to address FI by integrating within clinical care, particularly for children and families. Simultaneously, there are systemic barriers that may prevent or limit the ability of the health care sector to engage in this space. This is the case for federal nutrition programs, many of which are intended to improve the food security of children but are not specifically designed for implementation within the health care setting. In addition to leveraging federal nutrition programs to directly assist patients experiencing FI, health care systems can have an even more broad and sustainable impact by fostering a policy environment that enables or incentivizes cross-sector collaboration. We use the exemplar of the United States Department of Agriculture’s (USDA) Summer Food Service Program (SFSP) to demonstrate that (1) it is feasible for health care systems to leverage federal nutrition programs; (2) patients and families benefit when health care systems participate in these programs; and (3) advocacy for more inclusive and flexible policies regulating these programs is essential to facilitating health care’s participation.
The USDA’s SFSP has been successfully implemented in health care systems since at least 2015. The SFSP is a federally funded, state-administered program providing children with access to free, nutritious meals in summer months when schools are not in session and during unanticipated school closures.4 The SFSP is underutilized, serving <15% of children who receive free and reduced-price lunch during the school year nationally, and the health care setting has been proven as a potential point of entry to expand programmatic reach.5 Both Children’s Mercy Kansas City (CMKC) and Children’s Hospital of Philadelphia (CHOP) have been operating successful SFSP programs since 2016 and 2017, respectively, with increasing numbers of participating meal distribution sites and children served each year. Collectively, the hospital systems served 24 757 meals in the 10-week summer of 2019. Though SFSP implementation in health care has been demonstrated to be feasible and effective in terms of meal provision at the point of clinical care, connecting families to other community resources, and building positive experiences to increase comfort in accessing community sites, there are few health care-based SFSP sites. This may stem from challenges with integrating the program regulations into the unique setting of health care. For example, SFSP meals must be eaten on-site in a congregate setting at a standard meal service time. Although these regulations make sense at a more traditional settling like a summer camp, they are problematic for clinical areas that do not have a dedicated cafeteria or clinic visits that do not take place over the lunch hour. Flexibility to tailor the program to the unique clinical setting is needed to increase the feasibility of health care participation and expand the reach and impact of the program.
The importance of the health care system’s role in addressing FI, and serving as an SFSP site, was further underscored during the pandemic. As a trusted and safe community institution that remained open during the early pandemic, the health care setting served as an important point-of-entry into community supports including food programs. In the spring of 2020, the federal government passed the Families First Coronavirus Response Act, granting the USDA authority to issue nationwide waivers supporting access to federal nutrition programs including the SFSP.6 The Child Nutrition Response waivers allowed flexibility to standard SFSP regulations to adapt the program to the increased need in the community, as well as increase safety of program operations with infection prevention measures and social distancing. With the streamlined procedures and operational flexibility offered by the waivers, both CMKC and CHOP were able to not only successfully operate during the COVID-19 pandemic, but also overcome some prepandemic challenges. Allowing meals to be eaten outside of traditional mealtimes, grab-and-go meal service and extended weeks of meal service amplified the impact of their programs, serving more than 150 000 meals collectively from March 2020 to August 2021, a >600% increase from the previous year.
As SFSP sites began to plan for summer 2022, the original Child Nutrition Response waivers were gradually being phased out. This left many programs in a state of uncertainty as they continued to struggle with downstream effects of the COVID-19 pandemic, such as supply chain shortages and increased food prices. Health care-based SFSP sites faced the additional barrier of continued increased infection prevention and control measures, still necessary to protect their vulnerable patients, even if their surrounding communities had loosened or eliminated all restrictions. In short, a return to prepandemic hospital operations was not possible, and thus a return to pre-pandemic SFSP operations in the health care setting was not possible. Ultimately, just days before the final Child Nutrition Response waivers were due to expire, Congress passed a bill including a new set of more limited, temporary waivers.7 The decision of whether to “opt in” to these waivers was left to individual state agencies. Since uptake varies by state, access to SFSP is inconsistent and operational challenges remain for many programs. For example, although CHOP was able to continue utilizing 2 of the key waivers that allowed the program to operate safely and effectively during the pandemic, CMKC was not able to use any waivers. With differences in waiver uptake by state in the summer of 2022, the consequences of health care-based programs operating under waivers compared with prepandemic operations may become more evident.
Our experience demonstrates that children’s hospitals are uniquely positioned to address FI by leveraging federal nutrition programs and underscores the important role of advocacy at the state and federal level to enhance programmatic flexibility, and thereby increase health care system participation. By temporarily allowing for more streamlined operations, the Child Nutrition Response Waivers illustrated the largely untapped potential of the health care system to improve access to federal nutrition programs without compromising program integrity. Additional policies allowing for health care-specific implementation and the flexibility to integrate these programs within the clinical workflow could lead to increased collaboration with community organizations and improvements in child health. Children’s hospitals are urgently needed to craft innovative solutions to address FI now, such as participation in SFSP, and to advocate for policies that will increase the positive impact that health care systems can have in the future. Advocacy is timely because the federal government has elevated the issue of FI with acknowledgment of its health effects and prioritization of solutions with the White House Conference on Hunger, Nutrition, and Health in the fall of 2022, as well as the ongoing child nutrition program reauthorization. It is essential for policymakers to hear from children’s hospitals when making decisions about how to administer, regulate, and fund these programs to successfully implement in the health care setting and have the greatest benefit for children.
Drs Plencner, Krager, and Cullen led the advocacy work at Children’s Mercy Kansas City and Children’s Hospital of Philadelphia, drafted the manuscript, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLAIMER: Dr Plencner serves on national advisory group for No Kid Hungry Early Childhood Team and received an honorarium for her time and service. All other authors have indicated they have no conflicts of interest relevant to this article to disclose.
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