Meals on Wheels Doesn’t Work? Really?

In defending the administration’s budget proposals, OMB Director Mick Mulvaney singled out Meals on Wheels and after-school programs as programs that “don’t show results” and are thus deserving of significant cuts in funding. Later, Mulvaney described these cuts as “about as compassionate as you can get.” (More on his comments about after-school programs in another post.)

In the interest of full disclosure:

• I have delivered meals-on-wheels (as a volunteer).
• I have had the life privilege of knowing one of the creators of Meals on Wheels (and have come to believe it is one of the most interesting social program innovations of our time).
• I have a relative who is a leader in an interesting extension of the meals on wheels concept: customized home delivered nutritious meals for individuals with medical and chronic conditions (such as HIV).

The choice of Meals on Wheels as Mulvaney’s example is remarkable, because in so many ways it is the model for a social program designed and operated using conservative principles: voluntarism, public-private funding, state and local block grant discretion, and high levels of efficiency. Funding for the program comes through Older American’s Act support; Community Development Block Grants; state, county and city funds; and private philanthropy.

It is also a remarkable choice because unlike so many social programs, there is a corpus of evaluation literature demonstrating program effectiveness, cost effectiveness, and indirect benefits to recipients and communities.[i] The evaluation literature shows improved nutrition, socialization, health status (e.g., reductions in falls), and diversion from nursing homes that otherwise would have been paid for by Medicaid. Costs per meal, costs per year, and cost offsets that would be necessary from other health and social service programs are extremely impressive.

The United States has had less consciousness of social isolation than many other countries, especially the U.K. From personal experience though, I can say that Meals on Wheels is one of the only, and certainly one of the most effective, interventions for older people and disabled persons who are isolated and homebound. Often, the person who delivers the meal – and has a regular conversation – will be the only human contact a home-bound person will have.

Over the past decade, funding for Meals on Wheels has dropped precipitously, especially under the Sequestration limits. Meals on Wheels America reports that 23 million fewer meals are being served now than in 2015. Waiting lists for services are reported across the country.

In an earlier post, I worried that Mulvaney and the administration would use claims for evidence-based budgeting as a stick for rampant budget cuts, irrespective of what the actual evidence shows.

Identifying Meals on Wheels as the exemplar of an ineffective program is not only wrong-headed, it is also extremely stone-hearted. Targeting a cheap and effective program that serves socially isolated older and disabled persons? Really?

You have to wonder if Mulvaney’s use of Meals on Wheels as an example is calculated, a declaration of a budgetary war where there will be no sacred cows. Even some of the most fiscally conservative members of Congress had an immediate allergic reaction to this announcement. The response from the media, advocacy groups, and social media has been scathing.

When the dust settles, it is likely that Meals on Wheels will fare well in the budget process. Nonetheless, it is an early and telling example of how evidence based budgeting will be used to justify some very draconian funding proposals.

[i] See for example, Kali S. Thomas and Vincent Mor, “Providing More Home-Delivered Meals Is One Way To Keep Older Adults With Low Care Needs Out Of Nursing Homes,” Health Affairs (October 2013), pp. 1796-1802; “The Relationship between Older Americans Act Title III State Expenditures and Prevalence of Low-Care Nursing Home Residents,” Health Services Research 49:3 (June 2013), pp. 1215-1226; and Huichen Zhu and Ruopeng An,  “Impact Of Home-Delivered Meal Programs On Diet And Nutrition Among Older Adults: A Review,” Nutrition and Health 22:2 (June 2014), pp. 89-103.