This article was written with the support of a Kaiser Permanente Institute for Health Policy fellowship.   Coretta Dudley’s monthly grocery shopping strategy is as finely calibrated as a combat plan. Armed with $868 in Supplemental Nutrition Assistance Program (SNAP) benefits (the fancy new name for food stamps), she stops first at FoodMaxx, a discount supermarket in East Oakland, where she stocks up on four weeks’ worth of nonperishables: cases of noodles, cans of vegetables and boxes of the sugary cereals her kids like. She also buys fresh fruit—apples and pears and bananas and grapes—but those will be gone in a week. Then she swings by Wal-Mart for bread, eggs and milk. Later, she’ll hit the family-owned meat market, where she chooses hamburger and cube steaks. Other than $100 she sets aside to replenish the milk, eggs and cheese later in the month, that first multipronged attack will last her and her six children, ages 4 to 16, the whole month. That’s the idea, anyway.

“At the end of the month, we’ll still need something,” she says. “It never fails.”

Almost 500 miles away, in the City Heights neighborhood of San Diego, Tsehay Gebere has developed her own shopping plan at the Saturday farmers’ market. The lines are long, and the ten-pound sacks of oranges, plentiful at 9 am, will have disappeared by noon. But Gebere, a weekly fixture at the market, has the inside track. She persuades farmer Bernardino Loera to sock away four bags in his van. Forty-five minutes later, she gets back to Loera’s stall and collects her hoarded prize.

Like Dudley, Gebere receives food stamp benefits, for herself and her four children. Like Dudley, Gebere shops at discount supermarkets like Food 4 Less for most of her groceries. But while Dudley buys four bags of fruit every month, Gebere buys at least four bags every week—made possible by the free money she gets at the farmers’ market.

Yes, free money—though the technical name is “double voucher.” The market matches a certain amount of money from a customer’s federal food assistance benefits, essentially doubling the customer’s purchasing power. City Heights was one of the first double voucher markets in the country; there are now more than 160 participating farmers’ markets in twenty states. They reach just a tiny fraction of the more than 43 million Americans receiving food stamps. But their very existence raises questions about SNAP’s identity: is it a welfare program or, as its recent name change suggests, a nutrition program? These questions are the subject of lively debate in USDA offices and advocacy circles, where the idea of giving extra money for fruits and veggies, innocuous as it may seem, is exposing fault lines between traditional advocates for the poor and a new coalition of healthy-food activists.

The underlying premise of the modern food stamp program, shaped in the Kennedy/Johnson years, was that the American poor were starving and in need of calories, any calories at all. But there is now a well-documented overlap between the country’s staggering rate of “food insecurity” (the term used by the USDA in lieu of “hunger”) and its escalating obesity rates. In 2009, 43 percent of households below the federal poverty line experienced food insecurity. And if you’re poor, you’re more likely to be obese. Nine of the ten states with the highest poverty levels also rank in the top ten of obesity rates.

That one can be simultaneously food insecure and obese seems like a paradox. But consider that many low-income neighborhoods have few full-service supermarkets. Grocery shopping in the neighborhood likely means buying at corner stores with limited options for healthy choices. Even if those options do exist, they are not necessarily the rational economic choice for someone on a tight budget. The cost per calorie for foods containing fats and oils, sugars and refined grains are extremely low, but these are precisely the foods linked to high obesity rates. Healthy choices like fruits and vegetables are as much as several thousand times more expensive per calorie.

In a California Department of Public Health survey of eating habits, low-income people said they knew the importance of healthy eating. But they still eat fewer fruits and vegetables than the government recommends, less than the American population as a whole. “People said they couldn’t afford it,” says George Manalo-LeClair, legislation director with the California Food Policy Advocates. “It’s cost.”

At the heart of this whole mess—poverty, hunger and declining health—is the food stamp program. Nationwide, the average SNAP beneficiary received $125.31 per month in fiscal year 2009. If food stamps constitute a person’s entire food budget—as often happens, even though the program is intended to supplement recipients’ own money—that translates to just under $1.40 per meal. If you’re looking to buy something that will satiate you for $1.40, you probably won’t be buying broccoli.

Researchers have long studied whether food stamps contribute to obesity. Previously the conclusion was, probably not. But in an Ohio State University study released in the summer of 2009 the finding was, quite possibly yes. The study found that the body mass index (BMI) of program participants is more than one point higher than nonparticipants at the same income level. The longer one is on food stamps, the higher the BMI rises.

If the link exists—and it is exceedingly difficult to prove a causal relationship between food stamps and any one physical condition—it exposes a weakness in the program. The food stamp program has certainly evolved since the “war on poverty,” but fundamentally it is still operating as though the only health threat facing the poor is insufficient calories.

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The roots of the City Heights farmers’ market date back thirty years, to an incident in 1980 Gus Schumacher calls “the case of the broken pear box.” Schumacher was helping his brother, a farmer outside Boston, load a truck after the Dorchester farmers’ market closed when he dropped a box of Bosc pears in the gutter. A woman passing by bent down and retrieved the damaged fruit, explaining that she was on food stamps but still couldn’t afford fresh fruits and vegetables for her children. Schumacher ended up giving her an additional ten pounds of apples and pears. “People should not be picking fruit out of a gutter,” he says.

A former under secretary in the USDA, Schumacher is now vice president of policy at Wholesome Wave, a Connecticut-based nonprofit that helped City Heights and similar programs get off the ground. For him, the broken pear box was a revelation: people on food assistance desperately want the products that small farmers like his brother were selling. If those pricey pears could be made affordable for these new shoppers, it could be a win-win for buyer and seller.

City Heights was an ideal community to put Schumacher’s theory to the test. The average income in the neighborhood is around $26,000, as opposed to $63,000 in the county as a whole. The types of fruits and vegetables on offer are tailored to fit the cultural preferences of shoppers, mostly Latino, Vietnamese and Somali. The market’s operators say more than 1,800 customers, 250 of whom are regulars, participate in their double voucher program, dubbed “Fresh Fund.” In a survey of marketgoers, 90 percent said that they include more fresh fruits and vegetables in their daily diet, thanks to Fresh Fund. The market’s small farmers have reaped benefits too. Bernardino Loera, Gebere’s orange vendor, says Fresh Fund dollars account for three-quarters of his sales.

City Heights customers say they love the quality of the market’s produce—“the food is so fresh,” “it’s natural,” “it’s organic.” But it is also surprisingly economical, given the reputation farmers’ markets have for designer produce. Lemons run six for $1 here; at the Albertson’s down the street, lemons were selling two for $1. Other items, like kale and onions, were pretty much equal to Albertson’s offerings. Loera says he adjusts his prices to match what customers can afford. The wares are made even cheaper by the Fresh Fund. Each time shoppers visit the market, their SNAP electronic benefits transfer (EBT) card is swiped, and they receive wooden tokens in $1 denominations they can use at individual stalls. The Fresh Fund is a true match program. Customers can deduct up to $20 per month from their benefit accounts; they then receive an equal amount in Fresh Fund dollars.

In three years, Wholesome Wave and its affiliated programs have secured funds from major philanthropies, including Newman’s Own Foundation and the Kresge Foundation. The group had a $1.4 million operating budget last year, and Schumacher expects $1 million more in 2011. But the real money is federal money—almost $70 billion spent in fiscal year 2010 on SNAP. If just 3 percent went to fruit and vegetable incentives, that would be more than $2 billion to make healthy food affordable at farmers’ markets and grocery stores.

Incentives are already on the radar at the USDA. Later this year, a fifteen-month pilot program in Massachusetts will attempt to apply the double-voucher theory—extra money for healthy foods—to the supermarket, where most food stamp purchases are made. Taking advantage of SNAP’s EBT card, which functions like a debit card, the program will add 30 cents to select recipients’ SNAP balance for every dollar spent on fruits and vegetables—fresh, frozen, canned or dried. The experiment cuts to the heart of nutrition incentives: would a little extra money back change people’s shopping behavior—and how much money would it take to make an impact?

Food stamps have long had a vigorous network of advocates in Washington; the healthy-food advocates are the new kids in town, with backgrounds in public health with emphasis on nutrition. The convergence of the two groups has not been particularly graceful. “I have to say we got off to kind of a rocky start,” says Manalo-LeClair, whose organization has worked with both types of groups. “People were pleased that the food stamp program has the ability to fight hunger, and we haven’t solved that problem. So then they were saying, ‘Are we asking too much to have it do more in terms of preventing obesity as well?’”

To some in the anti-hunger lobby, the emphasis on nutrition is a political Trojan horse, a pretext for cuts or restrictions to the program. “Nine times out of ten, the people in these debates who use the term ‘reform’ use it as a sugarcoated way of just slashing benefits,” says Joel Berg, director of the New York City Coalition Against Hunger. Indeed, the link to obesity has been raised in Congress as a reason not to increase funding for the program. Also, critics worry that it’s a short road from incentives to disincentives: New York City Mayor Michael Bloomberg recently suggested banning the use of SNAP benefits for sugary soda, and Schumacher once proposed a surcharge for Coke and Twinkies (he has since dropped the idea). To some, this approach smacks of paternalism, implying that low-income people cannot be trusted to make their own decisions. “The right and left said we were being nannies,” says Schumacher.

The people who run City Heights argue that their initiative would actually expand choices for low-income people who want to include fruits and vegetables in their everyday diet. Imagine if everyone on food stamps enjoyed the same choice. What if there was a place like City Heights in East Oakland, where Dudley could get $20 more each month to spend on fresh produce? Is that something she’d be interested in?

“If they’d match me? Yeah…” She trails off, imagining how that would work. “Yes!” she says, getting louder now. “Oh, my God—I would love that!”

Maybe she could buy fruit all month long. Maybe fresh vegetables wouldn’t just be for holidays. For a moment, Dudley adjusts her battle plan to indulge in this new fantasy.

“Twenty dollars a month,” she says. “That would change a lot.”