Many State Medicaid Programs Fall Short of Adequate Home Intervention Coverage for Asthma Care

Home interventions to remediate many of the housing conditions that trigger asthma are proven, evidenced-based and cost effective. Interventions are recommended by the foremost authority on asthma care in the country, the National Asthma Education and Prevention Program’s Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3). Yet few state Medicaid programs cover home intervention services, despite their efficacy at preventing asthma episodes in children. Last month, the American Lung Association (ALA) released results of its Asthma Care Coverage Project that tracks state Medicaid programs’ coverage of asthma care. GHHI was asked to be part of the advisory group for the project and provided expertise on environmental asthma trigger reduction. The results found that out of 23 states surveyed, only four (4) states covered home visits and interventions without barriers. Three (3) states had coverage but with barriers, another six (6) states had some coverage but barriers were not necessarily always present, and ten (10) states had no coverage for home visits (see map).
ALA looked at seven categories[1] of evidenced-based asthma care management as defined by EPR-3’s Guidelines and similar expert documents, including the Guide to Community Preventive Services. In the category of ‘Home Visit and Interventions’, a state was considered covered if there was a low-intensity service that had two of three components (education, assessment, or intervention), and addressed either integrated pest control or two other asthma triggers (smoke, mold, pets, dust mites, VOCs, combustion sources) This means that even if a state does not conduct interventions, such as carpet removal, venting of bathrooms, or water infiltration repair, it can still be rated as having home visits and interventions covered.
Even with this relatively low bar, in the 23 states that were part of the study, only four (4) states covered home visits and interventions without barriers. (ALA first studied the 23 states that had CDC-supported state asthma programs, and will be looking at the remaining states this fall.)
For a condition as prevalent and serious as asthma, causing over 3,000 deaths each year, these findings are unacceptable. Home interventions are proven, evidenced-based, and cost effective. GHHI’s study, Improving Health, Economic and Social Outcomes Through Integrated Housing Intervention as published in Environmental Justice in 2014, found that home interventions reduced asthma-related hospitalizations by 65 percent and emergency room visits by 27 percent. The Guide to Community Preventive Services found that home interventions have a $5.3 to $14 return for every $1 invested. In GHHI’s work around the country, we’ve found that the greatest barrier to covering these home interventions is the perception that services are not “medical care”. But should states leave millions of Americans without adequate care coverage because of misperceptions?
We do see promising developments that may herald Medicaid coverage for home interventions.  GHHI is working in ten states to move the bar forward, and is in the midst of discussions on how more comprehensive home services to address asthma fit within the movement in Medicaid toward value-based payments. The purpose of the ALA study is to gather information so that states will move toward covering every part of guidelines-based care.


[1] The seven categories are: Quick relief medications, Controller medications, Devices, Allergen testing, Allergen immunotherapy, Home visit and interventions, Self-management education
 


 

How Can Partnering with the Housing Sector Improve Health?

Housing and Health
The home has long been thought of as a place of refuge, a place where we can be safe.  However, for many low-income families, the home is a source of significant stress and harm.  Affordable housing is often hard to find for low-income families, and in many cases families end up in deteriorating homes with health hazards such as mold, chipping lead paint, exposed wiring and poor ventilation, which lowers their value.  Even with the lower prices, low-income families still spend an average of 50 percent of their income on housing, much higher than the national average.  In addition, an average of 16 percent of their income goes toward utility costs, compared to 3.5 percent for the rest of the population.  In the U.S., there are about six million families living in households with moderate to severe home health and safety hazards, which increases their risk of housing-related illnesses such as asthma, lead poisoning, slips and falls, and other respiratory illnesses.  Many are forced to seek treatment from hospitals and medical professionals, which incurs an overwhelming burden of unaffordable medical bills. 
For families insured through Medicaid, the U.S. government covers most of these bills, amounting to billions of dollars annually in health care costs (ER visits, medications, hospital stays).  Unfortunately the government doesn’t cover these costs in full, so not only do families spend a significant amount of income on housing, they also spend a substantial amount on healthcare.  In addition to these expenses, society incurs a sizable loss in production as children and adults miss school and work respectively to treat their illnesses.  Finally, sick days can cause an increase in stress and exacerbate existing health problems, leading to more missed days of work and school. 
The Green & Healthy Homes Initiative seeks to prevent these negative outcomes by braiding together categorically separate but mission-related funding and programs to deliver healthy homes, weatherization, and energy efficiency interventions to low-income families. 
The GHHI Model
The Green & Healthy Homes Initiative promotes a more efficient approach to public health as it relates to the home.  Since 1993 GHHI has been working together with local partners to integrate and braid resources that deliver comprehensive home rehabilitation services to low and moderate income families. Our model begins with a holistic assessment of all the health hazards and energy inefficient areas within the home, in order to develop a comprehensive list of improvements that can be made. GHHI facilitates information and resource sharing between housing agencies and related organizations, helping them work together to develop a plan of action that captures efficiencies by working collaboratively. An example might include a Community Action Agency’s Weatherization program working with the city’s lead poisoning prevention program. Then, the home improvement project is completed as efficiently and in as few steps as possible, reducing traditional redundancies and overlap between agencies.  This also minimizes the amount of time family members have to take off work, and reduces the stress that comes as a result of missed work.  The last step is to provide education to occupants, outlining to families how they can further protect themselves from health hazards in the home. 
Our Impact
According to the Robert Wood Johnson Commission to Build a Healthier America, about 40 percent of asthma episodes are attributable to unhealthy housing conditions. In 2014, GHHI studied the effects that its intervention model could have on individuals, families, and communities.  The study looked at 139 individuals with asthma who received GHHI services.  We conducted a baseline assessment prior to the home intervention and a six-month follow up after the intervention.  The assessments measured the severity of the subject’s asthma condition, how well it’s managed, number of calls to the doctor, number of doctors’ visits, number of ER visits, number of hospitalizations, and how many days of school/work were missed.  At the conclusion of the study, subjects reported a 48 percent reduction in shortness of breath, a 65.5 percent reduction in hospitalizations, and a 37 percent and 27 percent reduction in missed work days and missed school days respectively, showing a correlation between housing interventions and improved health. 
Improved individual health outcomes have macro-level implications on our economy.  The annual direct health care cost of asthma is approximately $50.1 billion, which would decrease as we reduce hospitalizations and other medical treatment by preventing asthma episodes through housing interventions.  Furthermore, the indirect cost--including the loss of productivity--of asthma is around $5.9 billion.  This amount would inevitably decrease as children and parents miss fewer days of school and work due to asthma and other housing related illnesses.  Declining health care costs mean that more public dollars can be used for other government programs.  Though the GHHI model is designed to better public health through prevention of disease, its impact can be felt in a broad spectrum of areas. 

GHHI's Annual Executive Leadership Institute!

 
Please join us for our 7th Annual Executive Leadership Institute, presenting opportunities for educational sessions, direct dialogue with leaders from key sectors, cross-sector discussions, peer exchange and networking.

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The Leadership Institute offers the best and brightest thinking in the green and healthy housing movement and Pay for Success field. As the preeminent annual meeting of practitioners implementing an integrated health and energy based housing intervention system, this year’s Institute will cover an array of topics specifically designed to help you create a 2017 strategic plan to further your site’s goals. Sessions will include:

Integrated Partnerships: Outcome Broker Essentials and Learning Network Development

Engaged Electeds: Making the Healthy Housing Movement a Priority for Elected Officials

Site Sustainability: Making the Case for Your Impact

Site Data: Collecting Data and Presenting the Unseen Benefits of Healthy Housing

A Pay for Success Track that includes sessions on partnering with healthcare providers and presenting impactful data
ELI will also feature content experts and other GHHI sites from across the country to deep-dive into subject matter-relevant topics, such as:

Water Conservation

Healthy Building Materials

Aging Well

Renewables
The 2016 GHHI Executive Leadership Institute aims to deliver the tools and information to advance your work and help you lead important changes at the local, state and federal level.  
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Thank You to Last Week Tonight with John Oliver

A big thank you to Last Week Tonight with John Oliver on HBO, which aired a smart and thought-provoking piece that focused on lead poisoning in America on April 17th, 2016. John Oliver’s analysis was both hilarious and horrifying. Aside from the humor, there were two key points everyone should take away:

There is no safe level of lead in a child’s system (or anyone’s system for that matter).

It is far more cost effective to fund abatement and prevention programs than to treat the host of health problems associated with lead poisoning.
While this information is not new, John Oliver delivered it in a way that should change people’s understanding of this issue. The horrific crisis in Flint, Michigan, brought renewed exposure to this issue and what can happen when those elected to protect its citizens fail to do so. Beyond Flint, Oliver illuminated the startling fact that significant lead hazards still exist in the homes of over 24 million Americans.
While making those homes safe is expensive, funding lead abatement programs is an efficient use of public money. In fact, each dollar invested in lead paint hazard control results in a return of $17 - $221. At the same time, we also need to invest more in addressing other home health hazards like asbestos, carbon monoxide and asthma triggers like mold.
Even minimal exposure to lead is linked to higher rates of learning disabilities, hyperactivity, diminished IQ, hearing and memory loss as well as aggressive and violent behavior. Lead poisoning can lead to a lifetime of other health problems such as cardiovascular disease, kidney problems and reproductive issues – just to name a few. The effects of lead poisoning are irreversible, yet it is entirely preventable.
Despite the decades of ongoing advocacy effort and substantial success in lowering the number of children impacted by lead, communities across the country still struggle to contain lead poisoning. Today, more than half a million children under the age of 6 have dangerous levels of lead.
We hope coverage such as John Oliver’s will spur not only interest but action. A good start would be to fully fund programs at the U.S. Department of Housing and Urban Development’s Office of Healthy Homes and Lead Hazard Control, which has consistently been underfunded and unable to meet the full need nationally. A minimum of $250 million each year for five years has great potential to make meaningful progress.
If we, as a country commit to a well-funded coordinated strategy we can end childhood lead poisoning as a major public health threat. Our children are well worth the investment, together we can work to ensure that everyone has a safe and healthy place to call home.

Blaming HUD Does Not Advance Prevention

Recently, there has been a renewed and important focus on lead poisoning and its toxic legacy that has undermined generations of American children. This heightened awareness has been brought on by the horrific stories out of Flint, Michigan and the life of Freddie Gray in Baltimore. City after city, state after state have realized this is a national issue that requires renewed and urgent attention.
To deliver on the promise of ending this tragic, costly and entirely preventable problem – we need an updated national strategy and commitment – one that is audacious, ambitious and achievable.
As we advance this work, the one thing we should not do is blame the very agencies that have stood out as leaders in the effort.  A recent op-ed in the New York Times raised reasonable areas for improving regulations and guidelines on lead poisoning prevention at the U.S. Department of Housing and Urban Development (HUD). HUD itself has acknowledged these issues need to be reviewed and updated. But the headline writers and other media outlets got one thing wrong:  HUD is not to blame for the country’s ongoing lead epidemic. In fact, HUD has lead federal efforts to actually invest in the one cure for lead poisoning – primary prevention.  And its current Secretary, Julian Castro, is deeply committed to the overarching goal of ending lead poisoning by expanding HUD’s efforts and the efforts of other federal agencies.
A long history of misguided policies and practices has fueled the nation’s burden of lead poisoning. It includes our failure to ban lead-based paint in housing in 1922 when most every other developed country in the world did so, waiting until the 1970s to ban lead in gasoline and waiting until the 1980s to ban lead solder in our water lines. Mistakes also include failures of housing code enforcement and a lack of protection of low-income renters, inadequate investment in lead removal and a failure to adopt stronger lead-prevention policies.
The Green & Healthy Homes Initiative is proud to work closely with HUD and other federal partners to advance lead poisoning prevention. We are equally committed to calling on these partners to make advancements in improving our policies, investments and protections for our children and families.
 

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