How the State of Hawaii is Tackling Food Insecurity

On January 8, 2025, the State of Hawaii received approval from the Centers for Medicare and Medicaid Services (CMS) to extend its QUEST Integration § 1115 Medicaid demonstration. This waiver extension expanded Medicaid coverage for health-related social needs (HRSN) services, select Medicaid services for justice-involved populations within 90 days of their scheduled release, and various home and community-based services (HCBS) flexibilities, and more.

Additionally, this demonstration created opportunities for Hawaii health centers to provide tailored nutritional support to their patients. The The Hawai'i Primary Care Association (PCA) participated in conversations that informed the State's 1115 waiver submission on nutritional provisions and continues to support Medicaid as it determines how to implement the benefit.

Under the current Administration, advancing "Food is Medicine" is a prominent priority on the Make America Healthy Again (MAHA) agenda. This approach promotes efforts to address the growing health crisis in America. This includes introducing fresh thinking on nutrition, healthy lifestyles, and food and drug quality and safety.  

NACHC recently interviewed the Hawaii PCA to learn more about how they are working with the State of Hawaii to maximize the QUEST Integration demonstration. I spoke with Jermy Domingo, DrPH, Community Wellness Initiatives Director with the Hawaii PCA, to better understand their role in planning this waiver and maximizing its impact for the State of Hawaii.

Dr. Domingo began her public health career at Kalihi-Palama Health Center (KPHC), where she designed nutrition and physical activity programs for its diverse patient population, and went on to coordinate cancer patient navigation trainings, pilot screening navigation, and worksite wellness initiatives at 'Imi Hale Native Hawaiian Cancer Network.

Dr. Domingo oversees the development and implementation of community health and research initiatives and provides training and technical assistance to Hawaii's 14 Federally Qualified Health Centers.

How is the Hawaii PCA addressing nutritional insecurity among Medicaid patients?

A key policy recommendation for Primary Care Associations aiming to address food insecurity at a state level is to start by understanding their own food ecosystem. That means asking the important questions: What are your health centers already doing? What do they want to do? Because health centers are always at the cutting edge of innovation for their communities, understanding where they've been and where they want to go is vital to moving any initiative forward. Along with understanding your ecosystem, collecting strong data and evaluating that data will help you make the best case for these programs.

For example, Dr. Domingo discussed the work the Hawaii PCA has been doing to address nutritional insecurity through Medicaid. With Hawaii being located approximately 2,500 miles from the continental United States. About 85-90% of Hawaii's food is imported, which makes it particularly vulnerable to natural disasters and global events that might disrupt shipping and the food supply. At any given time, Hawaii has a 5-7 day food supply. Health centers have long worked to address the lack of access to nutritious food, from local food pantries, and nutritional guidance to structured screenings and pilot programs. Efforts that have been held together by short term grants and temporary funding, leaving a level of uncertainty for the State of Hawaii.

During the COVID-19 pandemic, food insecurity became more apparent. Being able to understand your ecosystem and having data that supports those needs provides a stronger case for health centers which can lead to obtaining and maintaining funding. With the lack of funding, it can lead to work stopping due to the inability to keep staff and resources. "When the grants end, it leads to a shortage of staff which results in the work stopping," Dr. Domingo stated. "It made the need glaringly clear. The community needed consistent support, not just emergency response." Now, with QUEST Integration waiver, there's an opportunity to change that.

The Four Pillars of Nutritional Support

Hawaii's waiver outlines four pillars for nutritional support: nutrition instruction, food and pantry restocking, medically tailored meals, and produce prescription/protein boxes. The Hawaii PCA recently conducted an assessment and found that the majority of Hawaii health centers are already engaged in nutritional guidance programs, many of which focus on chronic disease prevention and management and healthy eating. About a third of the health centers offer produce prescription programs.

Some have even developed formalized structures for prescribing fruits and vegetables to patients with specific conditions like obesity or diabetes. And through support from the National Association of Chronic Disease Directors, the Hawaii PCA was able to launch an "umbrella hub" that helps support and build capacity across its member health centers to implement evidence-based prevention initiatives at scale.

What is Medicaid's role in addressing Food Insecurity?

Another policy recommendation for PCA's looking for guidance with addressing their food insecurity is by engaging with stakeholders. One of the big stakeholder engagements that helped cultivate this program for Hawaii was their involvement with their state Medicaid office. Hawaii PCA's involvement began about two years ago, when they were invited to early community-engagement discussions around the Nutrition Supports with the state's Medicaid office. This engagement involved regular meetings with the planning team to review aspects of their application and offer insights from our health centers.

In anticipation of this waiver and guidance from our Payment Reform Advisory Committee, HPCA brought together dietitians, community health workers (CHWs), providers, and other community leaders and experts to help inform implementation strategies and conversations with the state's Medicaid office. Understanding the importance behind stakeholder engagement also means knowing that the process is not easy due to external factors that may be out of your control.

"There's some uncertainty with how quickly things will move under the current administration," Domingo noted. "We've been told nutritional support will likely roll out in 2026. In the meantime, we're helping health centers get ready."

From a policy standpoint it is highly recommended to expand collaborations because collaborations should not only be restricted to the usual suspects. Create those fundamental relationships with people and organizations who are specializing in the field that includes food banks, local farms, and community groups. They are powerful allies and provide a testament that the government agencies may not be able to provide. Within Hawaii's QUEST Integration demonstration extension waiver, Hawaii introduced new initiatives and investments to improve health coverage, access, and consistent provision of high-quality services for Medicaid beneficiaries. For the Hawaii PCA and its network of community health centers, they understood that this could be transformational.

"Many centers had to pause food programs in the past due to funding issues. With this waiver, they can now restart with more stability and intention," Dr. Domingo shared. "It's about more than just handing out food, it's about giving providers the tools and confidence to ask the right questions and provide the right support, including medically tailored meals and groceries based on health needs."

Even though the state is still in the planning stages, some health centers have already started pilot programs. One example includes a diabetes management program offering medically tailored meals, combined with education and cultural context to reinforce long-term behavior change. "These programs are showing strong outcomes," Domingo said. "But we're also learning in real time, asking whether it's sustainable, and whether Medicaid will provide ongoing support."

When asked what success will look like if the waiver reaches its full potential, the answer is both practical and hopeful: "We'd see better health outcomes and stronger engagement from patients. Communities would feel trust in their healthcare system, and we'd see less food insecurity and food waste. Farmers and community-based organizations would be fairly compensated. Food would be local, fresh, and part of the solution." And most importantly, she added, "The solution is already in the community. We just need to listen, include their voices, and make sure we make space for them at the table."

With one in eight U.S. households (12.8%) experiencing food insecurity, or lack of access to an affordable, nutritious diet. Integrating nutritious food into clinical care can help address chronic conditions such as obesity, diabetes, and/or heart disease. With Community Health Centers being the largest primary care network in the United States, serving more than 34 million people, or one in 10, NACHC is determined to continue place health centers at the forefront of this mission. Many health center patients are experiencing food insecurity and food as medicine can be both preventive and restorative, and at NACHC, we believe that food access should be as integral to healthcare as any clinical service.