Healthy Homes and Health Reform
In less than a year, the Affordable Care Act (ACA) will extend health insurance access to millions of Americans who are in desperate need of medical coverage. Implementation of the ACA is expected to bring greater use of primary care services, better coordination of care and improved management of chronic diseases. While this will be a tremendous – and long-overdue – improvement, without a greater focus on preventing the onset of chronic disease, it will do very little to reduce the burden of healthcare costs on consumers, businesses and government.
Much like the ACA, Massachusetts in 2006 extended health coverage by expanding Medicaid eligibility, providing subsidies for private insurance and creating a regulated health insurance exchange. Now, with coverage rates at 98%, the Commonwealth ranks number one in the nation for access, but continues to experience soaring health care costs. Since 2006, we have seen greater portions of our state budget devoted to paying for health care,[i] increases in premiums and, until recently, no fewer emergency room visits than before we implemented health reform.[ii]
To address this problem, this past year the Massachusetts legislature passed an omnibus piece of legislation aimed at health care cost containment.[iii] The legislation is expansive in its reach, but it represents some of the best thinking about how to achieve the elusive Triple Aim: improving the patient experience, improving the health of populations and reducing the overall cost of providing care.[iv] Among the most important provisions are those that focus on the relationship between the clinical environment and the environment to which patients return after their visit to their provider. This includes the places we work, the communities where we live and the homes where our children are raised.
Bridging the Gap
Public health, and particularly those programs that focus on healthy homes,[v] are in a unique position to bridge the gap between the clinical setting and patients’ home environments. We know that poor housing conditions, including mold, pest infestations, poor indoor air quality and lead paint, impact the health of residents who are exposed, with a particularly adverse effect on children. Children who grow up in substandard housing are more likely to experience asthma, lead poisoning, developmental delays, mental health problems and unintentional injury.[vi] These chronic conditions can lead to a lifetime of additional health care needs, lower quality of life and, in some cases, disability.
In Boston, a team of city agencies in partnership with medical providers is at work to help reduce the impact of poor housing conditions on the health of residents. Through the city’s Breathe Easy at Home Initiative (BEAH), families of children with poorly controlled asthma can be referred to the city’s Inspectional Services Department. That department may conduct a housing inspection to explore the possibility of environmental asthma triggers in the home that may be covered by the Massachusetts Sanitary Code for Housing, and to encourage landlords to repair unsafe conditions. The Boston Breathe Easy at Home Program, which grew from serving 60 families in 2006 to 233 in 2012, is funded almost exclusively through City of Boston funds, but has been universally adopted by Boston’s clinical settings as a way to address poor housing conditions that contribute to expensive asthma episodes among their patients.
The city’s health department also offers a free asthma home-visiting program, including low-cost supplies to reduce allergens and toxins in the environment and to help identify asthma triggers, unintentional injury risks and lead poisoning threats. Asthma home visits to reduce environmental asthma triggers and to provide disease self-management education, social support and care coordination are recommended as they result in reduced symptoms days and other improvements and in savings on asthma care and productivity.[vii]
Other models of clinical care and public health coordination and integration have demonstrated improved health and cost savings. The Massachusetts Lead Law requires universal screening for young children. In Boston, once a child is identified through screening, a community health worker (CHW) employed by the local health department conducts a home visit including comprehensive home inspection for multiple hazards and arranges for the child to attend the monthly lead clinic at Boston Medical Center. The CHWs attend the clinic and continue to address social, economic and behavioral issues to improve the health and safety of the child and family. Since the year 2000, this comprehensive approach has resulted in an 89% decline of children in Boston ages 0 to 72 months with elevated blood levels.
Public Health’s Contribution
While all of these public health programs have been successful in reducing household health risks, they are largely supported through grants or with city, state or federal public health dollars, while savings are seen in the health sector. In recent years, the federal budget for programs such as lead poisoning prevention, asthma home-visiting and other healthy homes initiatives has been slashed. In the case of lead poisoning, the funding dropped a precipitous 93 percent in just one year.[viii] As providers of these programs struggle to maintain them in the current funding environment, medical providers are increasingly being asked to improve patient health outcomes in ways that do not utilize a lot of additional health care resources. In this environment, it behooves all parties to take a hard look at how to bridge the gap between clinical providers and public health. An organized, coordinated effort can result in improved health outcomes for individuals, reduced racial and ethnic health inequities, improved population health, and potential cost savings.[ix] But it requires all sides to step outside of their traditional roles and to devise a payment system that is completely new and recognizes the contributions of the public health sector in health improvement and cost savings.
[iv] Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, Health, And Cost. Health Affairs. 2008 May; 27(3): 759-769.
[v]U.S. Department of Housing and Urban Development. Leading our nation to healthy homes. Defines healthy homes as “homes are both affordable and designed, constructed, rehabilitated, and maintained in a manner that supports the health and safety of occupants.” Available at: http://portal.hud.gov/hudportal/documents/huddoc?id=DOC_13701.pdf .
[vi] Bashir, SA. Home is Where the Harm Is, Am J Public Health. 2002 May; 92(5): 733-738.
[vii] Task Force on Community Preventive Services. Recommendations from the Taskforce on Community Preventive Services to decrease asthma morbidity through home-based, multi-trigger, multi-component interventions. Am J Prev Med 2011;41(2S1):S1-4.
[ix] Stine NW, Chokshi DA. Opportunity in austerity—a common agenda for medicine and public health. N Engl J Med, 2012; 366;5:395-397
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