Insert:    
Visibility:     Module:   

Blog Posts

Threats or Promises: Which Way for the Trump Administration on Childhood Lead Poisoning Prevention?

Recent news articles suggest that Trump’s EPA hopes to drastically cut funding and staff for its lead poisoning prevention programs ("EPA Memo Outlines Plans to Defund Lead-Paint Program," in Remodeling, April 4; and "Trump’s EPA Moves to Dismantle Programs that Protect Kids from Lead Paint," in The Washington Post, April 5). This follows on the heels of a high-level meeting between the EPA’s new administrator, Scott Pruitt, and the National Association of Home Builders (NAHB). NAHB complained about so-called “excessive” regulations, specifically EPA’s Renovation, Repair, and Painting (RRP) Rule

But it was exactly inadequate regulations that led to the Flint crisis and others like it, such as the East Chicago disaster in Indiana, the vice-president’s home state.
 
The fact is that congressional action and regulations have worked: Blood lead levels in the nation’s children have been greatly reduced  as a result of the implementation of statutes and regulations (see "U.S. Policies vs. Children's Average Blood Lead Levels" below). When we as a nation mandated the removal of lead from food canning, gasoline, new residential paint, plumbing and other sources, all through regulations, it worked. If anything, the regulations should be strengthened, not weakened, because over half a million children still have blood lead levels above the CDC reference value.1 

Some industries have supported these regulations over the years,2 but a few others have actively opposed them.3 Most recently for example, the National Association of Home Builders (NAHB) wants the EPA’s RRP regulation restricted to only pre-1960 housing, even though lead paint was not banned (by regulation) until 1978. They want “training” of their contractors to be only online, when in fact construction contractors don’t really learn that way. They want a new cost-benefit analysis, even though many previous studies have already shown that the benefits far outweigh the costs.4, 5 NAHB already succeeded in previous years in eliminating a dust testing requirement that has existed for years in federally assisted housing rehab work with scientifically proven positive results.6 (Children’s blood lead levels in assisted housing are lower than in non-assisted low-income housing, and dust testing [dust is one of the main ways children are exposed] is the major reason why). NAHB should protect the interests of its members by ensuring that homes are safe, not cutting corners and weakening laws and regulations that, if anything, need to be strengthened. And it should work to ensure that its member contractors don’t inadvertently do sloppy work that can cost $100,000 per house to clean up.7

Furthermore, preventing childhood lead poisoning not only protects children, it will create at least 75,000 good-paying jobs.8

During his campaign, the president promised to fix things that don’t work right. What better example is there that lead poisoning needs to be fixed than the 24 million homes that still have lead paint hazards, or the 6-10 million homes that still have lead water pipes? The solution is not to weaken regulations or to cut budgets but to strengthen them, putting the resources in place to end this preventable disease. Lead problems are a sign of our crumbling infrastructure, something the president also vowed to fix. We think that an infrastructure bill should include lead poisoning prevention. 

At HUD, the new Secretary, Dr. Ben Carson, promised to “enhance” lead poisoning prevention and healthy housing, proposing to increase the budget for that program from $110 million to $130 million. But at the same time, the proposed HUD budget wipes out the multi-billion-dollar Community Development Block Grant (CDBG) program. Many local jurisdictions use CDBG to provide their local “match” funding, anywhere from 10% - 25%, for lead hazard control. So, even though the proposed increased funding for the lead program is welcome, it appears that with the CDBG proposed elimination, the net effect will reduce, not increase, the total HUD resources to protect our children from lead poisoning. Why give with one hand only to take away more with the other? 

The National Safe and Healthy Housing Coalition has produced a number of recommendations that will protect our children

We urge the new administration and the new Congress to act on those recommendations to improve (not weaken) regulations and to propose a budget that will get the job done.

Instead of paying over $50 billion a year for lead poisoning, let’s solve the problem, not eliminate EPA programs or reduce HUD funding. At its beginning, the Flint fiasco was supposedly an attempt to save money, and NAHB’s wishes sound just like that, don’t they? We cannot afford another Flint, and we cannot afford to continue to pay the high costs of needlessly poisoned children. In Flint and across the nation, we will now spend far more now than had we acted to solve the problem in the first place. And we do know how to solve it. We should act on what we know, put our people to work, protect our children, and stop wasting money by caving in to a few narrow short-sighted industries at the expense of the rest of us.





_______________

1 Wheeler, W., & Brown, M. J. (2013, April 5). Blood lead levels in children aged 1–5 years — United States, 1999–2010. Morbidity and Mortality Weekly Report (MMWR), 62(13), 245-248. Retrieved April 6, 2017, from https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6213a3.htm

2 National Safe and Healthy Housing Coalition. (2016). Declaration of the Lead and Environmental Hazards Association. Retrieved April 6, 2017, from  http://www.nchh.org//Portals/0/Contents/LEHA_Declaration_2016.pdf 

3 Jacobs, D. E. (2016 July-August). Lead poisoning: Focusing on the fix. Journal of Public Health Management and Practice, 22(4):326-330. doi: 10.1097/PHH.0000000000000430. Retrieved from http://journals.lww.com/jphmp/Citation/2016/07000/Lead_Poisoning___Focusing_on_the_Fix.2.aspx
   
4 Gould, E. (2009, July). Childhood lead poisoning: Conservative estimates of the social and economic benefits of lead hazard control. Environmental Health Perspectives, 117(7), 1162-1167. Retrieved April 6, 2017, from https://ehp.niehs.nih.gov/wp-content/uploads/117/7/ehp.0800408.pdf

5 Nevin, R., Jacobs, D. E., Berg, M., & Cohen, J. (2008, March). Monetary benefits of preventing childhood lead poisoning with lead-safe window replacement, Environmental Research, 106(3), 410-419. Retrieved April 6, 2017, from http://www.ncbi.nlm.nih.gov/pubmed/17961540
 
6 Ahrens, K. A., Haley, B. A., Rossen, L. M., Lloyd, P. C., & Aoki, Y. (2016, November). Housing assistance and blood lead levels: Children in the United States, 2005-2012. American Journal of Public Health, 106(11), 2049-2056. Retrieved April 6, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/27631737
 
7 Jacobs, D. E., Mielke, H., & Pavur, N. (2003, February). The high cost of improper removal of lead-based paint from housing: A case report. Environmental Health Perspectives, 111(2), 185-186. from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1241348/
 
8 National Center for Healthy Housing & National Safe and Healthy Housing Coalition (2017, February). Find It, Fix It, Fund It: A lead elimination action drive: Policy recommendations to Congress and the new administration. Retrieved April 6, 2017, from http://bit.ly/FFFAdmin

9 Jacobs, D., & Weinberg, A. (2017, February 22). Infrastructure and mortgages: What about the kids? National Center for Healthy Housing website. Retrieved April 6, 2017, from http://bit.ly/Infra_Kids



Dr. David Jacobs, former Director of the Lead Poisoning Prevention Program at the U.S. Department of Housing and Urban Development, is the Chief Scientist for the National Center for Healthy Housing and an adjunct professor at the University of Illinois at Chicago School of Public Health

Infrastructure and Mortgages: What about the Kids?


During the 2016 election season, Donald Trump (the Republican presidential nominee, now president) proposed spending $1 trillion dollars on infrastructure to put people to work and rebuild the sinews of the nation. Democrats have also called for infrastructure improvements. Those improvements must include making our homes and schools safe for our children. In its recent (January 2) editorial, "Housing that Ruins Your Finances and Your Health," The New York Times wrote, “One solution would be for Fannie Mae to eliminate dangerous lead conditions in foreclosed homes.” But lead requirements are antiquated or nonexistent not only at Fannie Mae but also at Freddie Mac and HUD’s FHA single-family mortgage insurance program. These federal housing programs are the only ones that were not reformed back in 1999 and are long overdue to be fixed.

In years past, both parties worked together to reduce childhood lead poisoning. But Flint is only the tip of the iceberg, and parents of lead-poisoned children are demanding that we do more to put a stop to the needless suffering. Lead poisoning costs us an estimated $50 billion annually for healthcare, substandard school performance, and lost work productivity (2008 dollars).1 The real tragedy is that we know how to fix lead hazards. The disasters in Flint and elsewhere could have been prevented and will now cost much more than if we had made the necessary upfront investments and reforms. The inadequate lead requirements at FHA, Fannie Mae, and Freddie Mac should comply with HUD lead-safe housing regulations, but they currently do not.

Traditionally, infrastructure spending only goes for roads and bridges and the basic equipment and structures that are needed for a country to function properly. But many are surprised to learn that the lead services lines bringing water into their homes are NOT part of the “infrastructure” and that the burden was on families to replace them. They are also surprised that home inspections required by mortgage companies do not include lead inspections. 

We think infrastructure and federally guaranteed mortgages should be used to make our homes safe for our children. Indeed, we have “shared” our homes with guests and friends and, of course, our families. But 37 million homes built before 1978 have lead paint,2 and at least six million homes have lead water service lines. This “shared” lead has poisoned millions of our children, sometimes poisoning one child after another as one family leaves and another moves in. Existing FHA, Fannie, and Freddie underwriting standards are part of the problem, but they could be part of the solution.

The biggest culprit is old single-pane painted windows, which have the highest lead paint and lead dust levels of any building component. Replacing windows is already a proven strategy. In a pilot program, Illinois replaced lead-contaminated windows in Peoria and Chicago in 500 homes,3 resulting in huge and sustained lead dust reductions not only on windows but also on floors; and many other studies have reached similar conclusions.

The time has come to replace all those old contaminated windows, those lead drinking water pipes, and the other lead hazards in our homes. Enormous benefits follow if infrastructure funds are used to address lead in homes:
  • First, over 75,000 jobs – good-paying jobs for both made-in-America window manufacturing and installation workers;
  • Second, increased property values anywhere from $5,900 to $14,300 per home4
  • Third, a return on investment of at least $17 per dollar spent on lead remediation or removal5
  • Fourth, up to $500 per household saved each year on reduced fuel bills, because new windows are more energy efficient.6 
With the right infrastructure improvements, we can all share safe drinking water and lead-safe homes. 

The evidence is clear – whether in small towns or big cities, rural or urban: We all win when we eliminate lead hazards and protect our children. Our traditional approach has been to respond only after a child is poisoned, but there is no reason to wait until the damage has already been done. We should test our homes and schools, not just our children’s blood. And we should insist that housing finance institutions like FHA, Fannie, and Freddie do the right thing and eliminate those hazards before children are poisoned.

As part of our new national infrastructure initiative, let’s include solving the lead problem. We urge the new president and Congress to protect our children. Let’s not wait for another Flint or another poisoned child. Get Fannie, Freddie, and FHA to do the right thing. Get rid of those old lead-contaminated windows and old lead pipes and put our people back to work to protect our children and our future.

_______________

1 Tresande, L., & Liu, Y. (2011, May). Reducing the staggering costs of environmental disease in children. Health Affairs 30(5), 863. Retrieved February 21, 2017,
from http://content.healthaffairs.org/content/30/5/863.long
2 Cox, D. C., Dewalt, G., O'Haver, R., Salatino, B. (2011, April). American healthy homes survey: Lead and arsenic findings. Washington, DC: U.S. Department of Housing and Urban Development. Retrieved February 21, 2017, from  https://portal.hud.gov/hudportal/documents/huddoc?id=AHHS_Report.pdf
3 Jacobs, D. E., Tobin, M.,Targos, L., Clarkson, D., Dixon, S. L. Breysse, J., et al. (2016, September-October). Replacing windows reduces childhood lead exposure: Results from a state-funded program. Journal of Public Health Management & Practice, 22(5), 482-491. Retrieved February 21, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/26910871
4 Nevin, R., Jacobs, D. E., Berg, M., & Cohen, J. (2008, March). Monetary benefits of preventing childhood lead poisoning with lead-safe window replacement, Environmental Research, 106(3), 410-419. Retrieved February 21, 2017, from http://www.ncbi.nlm.nih.gov/pubmed/17961540
5 Gould, E. (2009, July). Childhood lead poisoning: Conservative estimates of the social and economic benefits of lead hazard control. Environmental Health Perspectives, 117(7), 1162-1167. Retrieved February 21, 2017, from https://ehp.niehs.nih.gov/wp-content/uploads/117/7/ehp.0800408.pdf
6 Nevin, R., Jacobs, D. E., Berg, M., & Cohen, J. (2008, March). Monetary benefits of preventing childhood lead poisoning with lead-safe window replacement, Environmental Research, 106(3), 410-419. Retrieved February 21, 2017, from http://www.ncbi.nlm.nih.gov/pubmed/17961540



 
Dr. David Jacobs, former Director of the Lead Poisoning Prevention Program at the U.S. Department of Housing and Urban Development, is the Chief Scientist for the National Center for Healthy Housing and an adjunct professor at the University of Illinois at Chicago School of Public Health

Anita Weinberg is a Clinical Professor and the Director of the ChildLaw Policy Institute at Loyola University Chicago School of Law, which spearheaded lead poisoning prevention efforts in Illinois for over 10 years.

Post-Election Analysis: Healthcare Financing for Healthy Homes Services Still Hard, Still Possible, Still Important


Two days after the recent presidential election I had to make a decision. I was supposed to be getting on a plane to California so that I could give a talk about opportunities to finance healthy homes services through the healthcare sector. This is a presentation I have given many times. I think and talk about this subject every day (yes, even weekends, #PublicHealthNerd). But I found myself at a loss for what to say. My hesitation wasn’t even a commentary on the outcome of the election but rather a reaction to the plain fact that, regardless of whether the idea thrilled or repulsed me, our healthcare system might be about to undergo another radical transformation.

The word “might” in that sentence is important. Because it is the uncertainty of what the scale and nature of that transformation could look like that made me wonder why I should fly across the country to stand in front of a room full of people and pretend that I had any answers about how to navigate this new reality. About how we would continue our work to ensure and expand access to critical public health services like home-based asthma and lead poisoning follow-up services.

But then I remembered. I remembered three things.

First, I wasn’t going to this meeting for a one-way exchange. I always leave meetings like that with new knowledge and inspiration, and I was obviously in need of both.

Second, I started working on this issue back in 2005 when I was a research scientist with the New York State Department of Health, under such an unfavorable environmental health policy landscape that my supervisor at the time begged me not to throw away my young career on something that was, in her opinion, so fruitless and so fringe. True story.

Third, I ignored her advice and discovered that there were others already working at the fringe to expand access to preventive environmental health services through the healthcare sector. In fact, some of you had been there so long, you’d taken up permanent residence. And you welcomed me in, shared your stories, your strategies, your successes and failures. And as a result, I started to work. In those early years, that meant laying the groundwork for change that would come later. I learned as much as I could about different program models, about Medicaid and healthcare financing. I talked to absolutely everyone and anyone who had tried or even thought about trying anything remotely like what I was trying to do. I wrote policy proposals about once a quarter for four years, failing repeatedly to gain any traction but always listening to what fell short and using that information to sharpen my pitch and improve my approach. I led a team that invited the state Medicaid agency, a local health department home visiting program, and four Medicaid managed care plans to help design a pilot program that wasn’t aimed at adding to the evidence base that we could improve health outcomes and reduce costs but instead focused on answering their questions and concerns about how such a program could operate in the real world. And what happened is that we answered those questions, we did improve health outcomes, we did save money; and in 2011 when New York State’s Medicaid Redesign Team was looking for ideas for how to improve healthcare delivery in the state, they came to us to ask for a proposal to fund home-based asthma services (and other healthy homes services) through the Medicaid program. That proposal was recommended and endorsed by the Health Disparities Workgroup of the Medicaid Redesign effort, subsequently included in New York State’s approved mega-waiver application to the Centers for Medicare and Medicaid Services, and will ultimately be implemented by seven Performing Provider Systems across the state that are financed through a funding pool that is reinvesting $6.5 billion of the savings previous reforms generated for the federal program back into public health prevention initiatives, including home-based asthma services.

And by this point in the conversation with myself, I was on a roll. I reminded myself that as part of my work at the national level I already know that there are many ways to get this work financed and that many, if not most, of them predate the Affordable Care Act (ACA). I reminded myself that when we cross-tabbed the results of our nationwide survey of state Medicaid policies for home-based asthma and lead-poisoning follow-up services with states that had adopted Medicaid expansion, we found no pattern whatsoever. I reminded myself that the American Lung Association’s more recent map of coverage of home-based asthma services shows progress in both red and blue states and that the most recent state to join the ranks of those providing coverage of home-based asthma services was Missouri. Coverage of environmental health services can have bipartisan support.

Now, I’m not saying that the ACA hasn’t been important or relevant to this work. It is. It’s opened up some new opportunities, it’s meant that there were more people insured to benefit from the policies we put in place through the healthcare sector, and it has sparked a genuine interest from the healthcare sector in figuring out how to address social determinants of health, like housing, and how to shift costs from treating chronic diseases to preventing them. It’s meant there was momentum and enthusiasm to put these types of services and programs in place. So it has been important. But it hasn’t been everything. Because underneath that there was a foundation. There was a foundation made up of health plans like Priority Health in Michigan and the Monroe Plan for Medical Care in upstate New York who in the late 1990s and early 2000s were already investing in these services. And of community-based organizations, like the Asthma Network of West Michigan, who were ready to partner with them and tell the rest of us the secret to getting the job done. And of state- and local-funded initiatives, including the New York State Healthy Neighborhoods Program, which has operated continuously since 1985 reaching 7,500 homes or more every single year. And of ordinary people like me in red and blue states across the country who were busy laying the groundwork. And of the staff who designed the Asthma Community Network to help us find each other and the best practices we needed to get our work off the ground.

And here’s the thing: That foundation still exists, and it is stronger now than it has ever been. We have more examples than ever of how financing these services isn’t just good healthcare, it’s good business. We have good reason to believe that the value of this work will continue resonate across the political spectrum and evolving healthcare landscape. And we have a bigger army of ambassadors to carry that message for us.

So regardless of what happens next, we can always do those two things. We can look for the forward thinkers, the Priority Healths and the Monroe Plans, in each state or community, and in places where there aren’t any, we can shore up the foundation so that when the landscape changes again and the conditions are more favorable, we can be ready to transform these systems permanently. 

In the end, I got on the plane. I got back to work.

A few days later the Centers for Medicaid and Medicare Services announced their approval of a State Plan Amendment to use federal and state funding to expand lead abatement activities in the impacted areas of Flint and other areas of Michigan. And I remembered two more things. This work is not only possible, it’s imperative.



Note: Interested in putting home-based asthma services or lead poisoning follow-up services in place, but not sure where to start? Whether you’re a community-based organization, healthcare payer, healthcare provider, public health agency, or housing organization, NCHH and its network of partners can help. Contact askanexpert@nchh.org for more information or check out our new state-specific case studies and other resources in our Healthcare Financing Resource Library.

Disqus Comments

Archive

Archive by Years
Tags
Categories