System‐Level, Decision‐Making, and Program Operations During the Implementation of the Medicaid Direct Certificate ( DC ‐M) Pilot on Maryland Community School Meals

Background The Maryland Department of Education participated in the USDA's Direct Certification with Medicaid (DC‐M) pilot during the 2022–2023 school year. This program lets Medicaid‐enrolled students automatically qualify for Free or Reduced‐Price Meals (FARM) and incorporates Medicaid data into eligibility calculations for the Community Eligibility Provision (CEP), which allows high‐poverty schools to offer free meals to all students. This study assesses how DC‐M impacts CEP participation from a systems perspective, using a causal loop diagramming approach across 12 Maryland public school districts. Methods Semi‐structured, in‐depth interviews were conducted among stakeholders from school district offices of food and nutrition services. Inductive qualitative coding was applied to interview transcripts, identifying causal relationships among codes using Kumu software. Results Interview findings ( n = 12 interviews) identified 36 interconnected factors organized into five reinforcing feedback loops and one balancing loop, revealing three themes: school district landscape influence on student enrollment, federal and state policies' effects on school meal funding, and school‐level meal operations impacted by school meal policies. Implications for School Health Policy, Practice, and Equity Schools can increase meal participation through DC‐M. Conclusions This study uses a systems approach to pinpoint barriers and facilitators that can inform strategies for improving FARM eligibility and supporting CEP programs.