From CSA to HMO

By Nicole Tichenor, M.S.

Building a more sustainable food system requires rethinking how we produce, transport and consume food. It means considering multiple facets of sustainability – ecological, economic, social – and acting in ways that best promote these throughout the whole system. To do this, farmers, entrepreneurs, researchers and advocates across the country are developing innovative strategies. One in particular seems promising: connecting sustainable agriculture to the health care sector to promote healthier consumption. An example of this kind of partnership is the community supported agriculture (CSA) health insurance rebate.

This concept was pioneered by the FairShare CSA Coalition, which began this program in southern Wisconsin in 2005 with one local health plan and a small group of farms. Eight years later, the program has grown to include four health plans (Dean Health Plan, Physicians Plus, Unity Health Insurance, Group Health Cooperative of Southern Wisconsin) and more than 40 farms.  Two of these health plans also partner with other organizations to provide CSA shares, including FRESH Food Connection and the Farley Center Farm Incubator.

Here’s how it works: insurance policyholders read about member farms on the Coalition’s website, all of which are certified organic or have exempt status. They then contact a farmer directly to sign up and pay up front for the share, as with any traditional CSA. Finally, they fill out their respective health plan’s CSA rebate form (available online) and mail/fax it to the health plan with proof of payment and a copy of their sign-up form. A few weeks later, policyholders receive a reimbursement check for up to $100 for an individual contract or $200 for a family contract.

The FairShare partnership has been wildly successful. A 2011 study of the first five years of the program reported the total number of member farm shares offered yearly increased by 450 percent – from 2,000 to 9,000 shares. While the researchers could not control for other factors that could have increased membership, and thus could not attribute this increase to the rebate alone, previous share growth and interview responses suggested that the rebate was highly influential. On the consumer side, health plans issued more than 20,000 rebates in the first five years, with an estimated total value of more than $3 million.

Finally, member farms were drawing in customers who may not have otherwise joined a CSA. While this concerned some farmers because these shareholders often did not fully understand the CSA model (agreeing to shared risk, some unpredictability, etc.), this finding was what truly excited me about the program’s potential. These kinds of interactions between farmers and consumers are teachable moments about seasonality, food preparation and the hardships farmers face.  Although this path requires additional patience and innovation, we must be committed to changing hearts, minds and habits to create a sea change in the food system.

So, how have they done so well? According to that same study, one of the biggest factors in the success of this program is having an organization that serves as an intermediary between the companies and the farms. This took the form of a coalition, but a regional food hub could also be well suited to fill this role. Another key aspect of the rebate program’s popularity is shared advertising responsibility. The insurance companies promote this as a wellness benefit to their members, while FairShare promotes the program and the companies through education and outreach.

At least one other health plan, part of the Mayo Clinic Health System, has started a CSA rebate initiative. Available in Wisconsin and Minnesota, this program offers up to $100 for a CSA share per member household, and the requirements are similar to FairShare’s. Members have the option of choosing from a list of CSA farms on the health plan’s website or finding a farm on their own.

Other CSA health insurance rebate initiatives are on the horizon. The University of Maryland Extension and the Johns Hopkins Bloomberg School of Public Health are partnering on a project to begin this work in Maryland. Azoti, a marketing service that brings locally grown food shares to employees through their employers, is working with health plans and employers this year to adopt the rebate program in Ohio, California, and New York. Azoti secured an agreement this January with a company called FastSwitch, which agreed to partially cover the cost of its employees’ CSA shares.

The CSA rebate approach has the potential to be an all-around sustainability win: local farms practicing ecological agriculture can expand their businesses (read: more dollars in the local economy, fewer synthetic inputs) and consumers can have access to more affordable and tastier produce. We should invest in research to analyze the impacts of these programs on wellness and the cost of care.

We already know that obesity and diet-related disease risk factors are strongly associated with higher health care costs, but whether a CSA rebate improves dietary quality and related health outcomes remains to be shown.  By quantifying this, we can make an even stronger case to insurance companies, employers and investors for the connection between healthy people, healthy food and healthy farms.

Nicole Tichenor is a PhD student in the Agriculture, Food and Environment program at the Friedman School of Nutrition Science and Policy at Tufts University. She has experience in domestic food and agricultural policy spanning the local to national levels through previous work for the Douglas County Food Policy Council and National Family Farm Coalition. Prior to attending graduate school, she worked in food assistance and distribution in Kansas, which continues to inform her research perspective. She currently works on an interdisciplinary, multi-institutional USDA grant on regional food systems and food insecurity. She is a Friedman Fellow and a former Ellen H. Block Fellow, and she hopes to make a compelling connection between sustainability, health, and justice in the food system through research.

Farmers' market photo by USDAgov/Flickr

10 Responses to “From CSA to HMO”

  1. Kenneth Heaton

    I really enjoyed your article, it was very well written. What benefit does the health care provider receive? You state that “whether a CSA rebate improves dietary quality and related health outcomes remains to be shown.” There must be some reason why the health care provider offers rebates.

  2. Nicole Tichenor

    Hi Kenneth,

    Great question! The insurance companies see this as an investment in the health of their members. Many of them sponsor other wellness programs (such as Weight Watchers) in hopes that these programs can make their members healthier, and thus less costly in the long run. It’s a great idea and I hope it’s true – we’ve just never actually measured how much of an impact food subscriptions and the like can make on concrete outcomes like weight, obesity, etc.

    Take care,


  3. Karl Sutton

    Thanks for the blog. This is a great model. We have a foodhub – producer owned cooperative in Montana that has a multi-farm CSA as well as a wholesale division. The CSA has been working with a hospital in Missoula. Last year they piloted a 50 person CSA subscription through the hospital’s human resources. The next step is to firmly establish this employee benefit program and use the hospital’s relationships with insurance providers to engage the conversation about CSA wellness program benefits. I would like to see this expand to universities and state agencies. Imagine farm to college expanding from wholesale accounts to CSA subscription cost shares provided by the employer. Exciting work.

  4. Jeannette

    I really hope more insurance companies adapt this model. It is such a great way to give individuals accountability for their own health, particularly elderly people. Perhaps seeing healthy food as a “prescription” might encourage better eating habits. Plus, the savings would be a great way to reward those people who don’t rely as heavily on their insurance benefits.

  5. Alexa Liguori

    Hi Nicole, I am graduate student at the CUNY SChool of Public Health working on an MPH Nutrition. I am interning with JUST FOOD in NYC doing CSA network outreach which is similar to the Fair Share Coalition. I was intrigued by this article because I am working on my capstone and was looking to direct my research. You made a comment about how future research should be conducted on CSA and wellness in order for more programs to adopt a rebate model. I was wondering specifically from whom? Is it more important to look at those at risk for chronic disease, low SES, or wellness in general? Should the research reflect data that shows health improvements or healthy behaviors?

  6. Dr. Jenny Bruck

    Hi Nicole, I was wondering if you had a follow up article on where this is adaption is today. It would be great to see if we are still making strides on this.


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