• The Cost Can Be Debated, but Meals on Wheels Gets Results

    The following originally appeared on The Upshot (copyright 2017, The New York Times Company).

    Meals on Wheels has been delivering food to older people in the United States since the 1950s. Last year it served 2.4 million people. This week, after President Trump released his budget proposal, a furor erupted over the program’s future and effectiveness. Let’s look at the evidence.

    Mr. Trump’s budget proposes big cuts to discretionary spending. In a news conference on Thursday, his budget director, Mick Mulvaney, defended cuts to the Community Development Block Grant program by arguing that it was “just not showing any results.” (Some states give a portion of that block grant money to Meals on Wheels.)

    “We can’t spend money on programs just because they sound good,” Mr. Mulvaney said. “And Meals on Wheels sounds great — again, that’s a state decision to fund that particular portion to. But to take the federal money and give it to the states and say, ‘Look, we want to give you money for programs that don’t work’ — I can’t defend that anymore.”

    Despite expressions of alarm on social media, killing the community block grant program would most likely not kill Meals on Wheels. The financial statements from 2015 show that such grants amounted to just under $250,000, or about 3 percent of the total revenue for the program’s national resource center. More than 85 percent came from corporate, foundation and personal donations. Clearly, federal funding for the national program office isn’t the linchpin for its success.

    Public funds at the local level, however, are more substantial, and Meals on Wheels gets much more funding through a different federal program. The nutrition programs of the Older Americans Act support the Meals on Wheels chapters as they actually operate on the ground, and about 30 percent of the expense of home-delivered meals is covered by federal sources.

    A cut to this program would have a far more significant effect, especially since that support had been decreasing even before the new budget was considered. The Trump budget calls for a 17.9 percent cut in funding for this program’s parent agency, the Department of Health and Human Services, and it is quite possible Meals on Wheels could be affected. We won’t know until H.H.S. finalizes its budget.

    Now, what about the assumption, explicit or implicit, that the program has not achieved “results”?

    Meals on Wheels has been the subject of many peer-reviewed studies in the medical literature. So many have been done that there are several systematic reviews gathering these studies into various domains.

    In 2014, researchers explored the evidence on whether home-delivered meal programs improved the diet and nutrition of older Americans. They found eight studies, two of which were randomized controlled trials. Six of the eight showed that programs like Meals on Wheels improve the quality of people’s diet, increase their nutrient intake, and reduce their food insecurity and nutritional risk. They also noted that the programs increased chances for human contact and improved quality of life.

    A 2015 review found that 80 studies have been conducted on programs like Meals on Wheels. The authors noted, however, that few of these were randomized controlled trials, and that even fewer focused on the program as a whole. They were correct, and I am sympathetic to these calls for more rigorous trials. But such trials are hard to do, they’re expensive, and funding for them seems to be going down, not up.

    Saying that you want better evidence is different from saying that there is no evidence, though.

    It’s important to recognize that the program’s benefits are not merely nutritional. A 2016 study showed that participants in the Meals on Wheels program had lower loneliness scores. A 2013 study showed that spending on services like Meals on Wheels was associated with less reliance on institutionalized care, because more people could live independently at home. They may even have fewer falls at home and less worry about being able to remain there.

    Finally, although no one measures it, Meals on Wheels brings people food they otherwise wouldn’t have.

    Researchers conducted economic analyses in 2013 and showed that if all states had increased the number of older Americans who had received Meals on Wheels by just 1 percent, the states would have saved Medicaid more than $109 million. Most of those savings would have come from reductions in the need for nursing home care.

    We can debate the cost-effectiveness of Meals on Wheels, but it would be wrong to say that it’s not effective. There are plenty of results, and I’ve highlighted only some of the most rigorous research available. Most programs we fund through tax dollars have far less evidence to support them, if any evidence at all.

    About the worst thing you might say about Meals on Wheels is that putting money into a different program might be of more help to older Americans. There’s no evidence that Meals on Wheels is the most cost-effective program there is, or that it’s the most efficient use of our taxpayer dollars.

    Any argument that goes in that direction, though, raises the question of whether there is a program that does a better job, and whether there is evidence to support it.

    @aaronecarroll

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