Issue Category: Public Health Funding

Rhode Island’s Efforts to Prevent and Respond to Childhood Lead Exposure

Background

In June 2016, the Rhode Island General Assembly passed the Lead and Copper Drinking Water Protection Act, requiring schools, day care facilities, public playgrounds, shelters and foster homes with children under six, and other state facilities to certify that drinking water conduits are lead-safe. It also directs state inspectors to conduct an annual lead and copper test at these facilities. In conjunction with the law, which will be implemented once regulations are promulgated, the state created a commission to study lead in the water system.

Documentation of Lead-Safe Remodeler/Renovator License Required to Receive a Building Permit to Complete Housing Renovations

In 2011, the City of Providence began requiring applicants for building permits at pre-1978 homes to provide proof of training and licensing in lead-safe work practices. The state of Rhode Island requires all construction contractors working in homes and child care facilities built before 1978 to hold a Lead-Safe Remodeler/Renovator License or a higher level of lead hazard control certification. The lead-safe remodeler/renovator program has been overseen by the state since 2001. It is authorized by the U.S. Environmental Protection Agency to administer the federal Renovation, Repair, and Painting rule in Rhode Island. To increase compliance with the state remodeler/renovator law, the City of Providence will issue permits for construction work at properties covered by the law only if proof of licensure is provided. In January 2015, the City of Pawtucket put in place a similar requirement: contractors must document their training and licensure to receive a building permit for renovations.

Use of Local Housing Officials to Enforce Lead Hazard Mitigation Law

The state of Rhode Island passed the Lead Hazard Mitigation Act in 2002 and implemented regulations in 2004. Under the law, rental property owners are required to attend a training on unsafe lead conditions, inspect/repair any lead hazards at their properties, make residents aware of their findings and actions, address residents’ lead-hazard concerns, use lead-safe work practices during maintenance, and verify each unit’s compliance through a lead inspector. Typically, the owner must have the property inspected every two years and prove its safety for children by showing a Certificate of Conformance (COC) or a Lead-Safe or Lead-Free Certificate. Owners of two- and three-dwelling properties who live onsite are exempt from the law.

Since the law’s enactment the state has been challenged by compliance. In 2014, when the Providence Plan completed an evaluation of the Lead Hazard Mitigation Law, it found that only 20 percent of the covered properties had complied with the regulations within the first five years of implementation. Several cities have taken steps to improve enforcement. Providence, for example, created a separate division of Housing Court to address lead violations.

The Inspection and Standards division reported that of 537 lead violation cases filed over the first four years, 484 resulted in corrective action. An analysis conducted by the Rhode Island Department of Health discovered that between 2012 and 2013, there was a significant decline in children with elevated blood lead levels in Providence. Notably, the declines coincided with the implementation of the building permitting requirements and the lead docket.

Medicaid Reimbursement for Lead Follow-Up Services and Lead Centers and Reimbursement

Rhode Island Medicaid, which covers nearly 40 percent of children in the state and roughly half of children below six with elevated blood lead levels, provides reimbursement for lead follow-up services under its 1115 demonstration waiver (known as the Rhode Island Comprehensive Demonstration). The waiver gives Rhode Island the flexibility to “redesign the state’s Medicaid program to provide cost-effective services that will ensure beneficiaries receive the appropriate services in the least restrictive and most appropriate setting.”

Lead follow-up services eligible for reimbursement in Rhode Island are provided through four “lead centers” certified through the state health department. Because the services are offered under specifications of the contract with Rhode Island Medicaid, the centers have the flexibility to hire a range of personnel to deliver in-home lead services. These include community health workers, nurses, and certified lead inspectors.

Medicaid reimbursement is currently available to the lead centers for follow-up services provided to Medicaid-enrolled children up to age six who are identified to have elevated blood lead levels. The lead centers bill by the “Current Procedural Terminology” billing code for each service provided to Medicaid recipients. Medicaid reimburses them for an initial visit, a follow-up visit, or to close the case. The lead centers are reimbursed by the state for services provided to non-Medicaid-enrolled children.

Follow-Up Services: Education, Case Management, Assessment, and Inspection

Written Rhode Island Medicaid standards require the lead centers to contact associated healthcare providers when providing lead follow-up services. For each child or family, the lead center identifies a specific case manager who handles all communication and coordination with the child’s primary care provider or treating physician, all treatment providers and community support agencies, and the child’s health plan, when appropriate. When necessary, the lead center case manager also works with the Rhode Island Department of Human Services and Department of Health, serving as the point of contact for the child, family, and all providers and agencies.

Along with case management, other Medicaid-reimbursable follow-up services provided to children under age six with elevated blood lead levels by Rhode Island lead center staff include:

  • Visual assessment of the primary residence
  • Nutrition counseling
  • Lead education
  • Interim controls to limit exposure to lead hazards
  • Information on safe cleaning techniques
  • In-home education

For children with blood lead levels elevated above the designated threshold (as set by the U.S. Centers for Disease Control and Prevention), Medicaid also reimburses for a Comprehensive Environmental Lead Inspection of the home by a Rhode Island Department of Health lead inspector. After the inspection, lead center staff review the results with the family to help them understand sources of lead in their home.

The lead centers provide some education and other services to children with blood lead levels that are high but do not exceed the designated threshold. However, these services are funded by a Rhode Island Department of Health contract, not by Medicaid. The services include an educational home visit to discuss lead poisoning, nutrition, and cleaning practices that can protect children from additional lead risks; a Visual Environmental Lead Assessment by a trained community health worker, which provides education and preventative next steps; and the provision of soil and dust wipes for the home. The Rhode Island Department of Health is also piloting a limited environmental investigation (soil testing only) in partnership with the lead centers for children with lower blood lead elevations that do not meet the designated threshold.

Additional Services: Structural Remediation

While Rhode Island Medicaid can provide some reimbursement for window replacement and spot repair of conditions found to pose a lead-related threat to children with elevated blood lead levels, this structural remediation benefit has been used rarely. The primary reasons include: (1) the current reimbursement rate for window replacements is less than the typical replacement cost and (2) the mechanisms by which lead centers receive this reimbursement are cumbersome. In an effort to increase use, the Rhode Island Department of Health is exploring ways to improve the window replacement program. One possibility may be a revolving loan fund since lead centers must pay for replacement first and seek Medicaid reimbursement later.

In addition, when a lead violation is found and a notice of violation issued, property owners and families are automatically referred to local Housing and Urban Development-funded lead hazard control grant programs that may pay for structural remediation. Access to these grant programs depend on income, the property’s age (pre-1978), and the presence of a child under age six living in or frequently visiting the home or unit. The Rhode Island Department of Health is currently assessing how often cited owners use these grant programs and whether or not there are enrollment barriers.

Use of Medicaid Reimbursement for Lead Follow-Up Services

This table from the Rhode Island Executive Office of Health and Human Services shows the total number of Medicaid-enrolled children who received lead follow-up services from the Rhode Island lead centers and the corresponding amount of total Medicaid reimbursement for selected years between 2006 and 2014.

Rhode Island’s current Medicaid 1115 demonstration waiver is in place through 2018, and there has been consistent support for the continuation of the lead follow-up service reimbursement program in the state. Stakeholders attribute this enthusiasm to the relatively low total cost of the lead program within Rhode Island’s overall Medicaid budget, along with the well-known dangers of lead poisoning.

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In August, 2017, the Health Impact Project, a collaboration between the Robert Wood Johnson Foundation (RWJF) and Pew Charitable Trusts released: Ten Policies to Prevent and Respond to Childhood Lead Exposure. The Trust for America’s Health (TFAH), National Center for Healthy Housing (NCHH), Urban Institute, Altarum Institute, Child Trends and many researchers and partners contributed to the report. TFAH and NCHH worked with Pew, RWJF and local advocates and officials to put together the above case study about lead poisoning and prevention initiatives.

The case study does not attempt to capture everything a location is doing on lead, but aims to highlight some of the important work.

Graham-Cassidy is Legislative Malpractice – It Would Greatly Harm the Nation’s Health

Joint Statement from American Public Health Association, Prevention Institute, Public Health Institute, and Trust for America’s Health

 

Washington, D.C., September 25, 2017 – Below is a statement from American Public Health Association, Prevention Institute, Public Health Institute, and Trust for America’s Health on Graham-Cassidy, which would cause millions to lose healthcare coverage, decrease access to clinical preventive services, and eliminate the Prevention and Public Health Fund.

“Graham-Cassidy would do untold damage to the nation’s health, unraveling the progress we’ve made to expand access to quality, affordable healthcare, reorient our healthcare system to value prevention and equity, and invest in a healthier future for all Americans.

Graham-Cassidy upends efforts to improve the nation’s health in the future by threatening to strip people of access to preventive care and zeroing out the Prevention and Public Health Fund. Over the next five years alone, states and communities stand to lose more than $3 billion in funding to prevent chronic disease, stop the spread of infectious diseases, and invest in resources that support health and equity. The Prevention and Public Health Fund also provides 12 percent of the Centers for Disease Control and Prevention’s annual budget. Losing this much funding—about $900 million a year—would irreparably damage our public health infrastructure, including our ability to respond to disasters and emerging epidemics. These short-term cuts will lead to more chronic conditions and exact a heavy burden of preventable illness and death – as well as higher healthcare expenditures for worse health outcomes – down the line.

Investing in public health makes the difference between health and illness, safety and injury, and life and death. The deep cuts this bill proposes – to Medicaid, to public health and prevention – would touch every community, especially those communities that are struggling most with longstanding inequities in health and safety.

Passing Graham-Cassidy is tantamount to legislative malpractice. The undersigned groups find this approach unacceptable and strongly urge Congress to work in a bipartisan manner  to improve the nation’s public health and healthcare systems.”

TFAH Statement on the ACA and the Prevention and Public Health Fund

Washington, D.C., July 28, 2017 – The below is a statement from John Auerbach, president and CEO, Trust for America’s Health (TFAH).

“TFAH is thankful that healthcare coverage will continue to be available for millions of Americans. We applaud the decision by the majority of senators to avoid the damaging repeal of the Affordable Care Act (ACA). As a result, millions can breathe a sigh of relief that their coverage will not be cut, their benefits reduced and/or their premiums become unaffordable.

That said, there is a need for continued support to increase and sustain access to affordable, high-quality healthcare, covering the range of needs from life- and cost-saving preventive care to comprehensive treatment.

And, importantly, efforts must ensure the Prevention and Public Health Fund remains intact. The Prevention Fund is one of the most important and biggest sources of funding for prevention-focused efforts, comprising 12 percent of the budget for the Centers for Disease Control and Prevention (CDC).

The Fund supports essential work at CDC and provides more than $600 million a year directly to states and communities to address their leading health concerns using the best public health approaches available. Without these funds, we are putting Americans across the country at unnecessary risk for health problems that could be prevented.”

 

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Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority.

Public Health Groups Decry Potential Elimination of the Prevention and Public Health Fund in Senate Bills

Joint Statement from American Public Health Association, Prevention Institute, Public Health Institute, Society of Public Health Education, and Trust for America’s Health

July 27, 2017

WASHINGTON, D.C. – The Senate is expected to soon vote on a ‘skinny’ repeal bill that would target key components of the Affordable Care Act – including potentially eliminating the Prevention and Public Health Fund.

This short-sighted move would cause long-term damage to our nation’s health. If the Prevention and Public Health Fund is eliminated, the pain of these cuts will be felt across the country, reverberating in every state and community. Over the next five years alone, states stand to lose over $3 billion in funding they rely on to prevent chronic disease, halt the spread of infections and epidemics, and invest in the community resources that support health and equity. It would cut the budget of the Centers for Disease Control and Prevention by 12 percent.

In the lives of individuals and communities, strong public health infrastructure makes the difference between health and illness, safety and injury, life and death. Slashing public health and prevention funding would increase preventable suffering and death, make the poorest and sickest communities fall even further behind, and leave our country far less prepared for and capable of responding to public health emergencies. The undersigned groups find this vision of the future unacceptable, and stand for prevention and public health.

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The Senate’s Latest Obamacare Replacement Effort will not improve the Nation’s Health, Affordable Care Act

Washington, D.C., July 25, 2017 – The below is a statement from John Auerbach, president and CEO, of Trust for America’s Health (TFAH) on the Senate’s motion to proceed.

“Each new iteration of Obamacare repeal legislation has failed to do what a health bill should: improve the nation’s health.

We know—according to the Congressional Budget Office’s scores on any number of the attempted bills—that tens of millions of people will quickly lose access to health insurance and the preventive services and programs which keep them from developing debilitating and costly chronic diseases.

That is, simply, the opposite of what a bill—intended to improve the nation’s health—should do.

Continued attempts to eliminate the Prevention and Public Health Fund would irreparably harm the nation’s health. States and communities rely on the hundreds of millions of dollars they receive annually to work on the critical health issues—including the opioid epidemic, lead poisoning, obesity, tobacco use and vaccine-preventable illnesses—facing their citizens.

To date, any funding included in repeal legislation for the opioid crisis has been nowhere near enough to solve the problem and will not make up for the substantially larger cuts to Medicaid and the Prevention Fund.

Estimates have found that the total coverage cost for people receiving treatment for substance misuse disorders could reach $220 billion over the next decade. And, people with substance misuse disorders often suffer from additional health problems – for example, mental illness and chronic conditions such as heart disease or diabetes – and need the routine access to care and services provided by Medicaid. As such, substance misuse treatment must remain part of the Medicaid integrated care system.

TFAH encourages the Administration and Congress to start over and create a true healthcare bill that will improve upon Obamacare, keep people covered and safeguard the nation’s health.”

Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority.

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The Senate’s Better Care Reconciliation Act is Irredeemable, would eliminate 12 Percent of CDC’s Budget for Fiscal Year 2018

Washington, D.C., June 22, 2017 – The below is a statement from John Auerbach, president and CEO, of Trust for America’s Health (TFAH) on the Senate’s Better Care Reconciliation Act.

“The Senate version is no better than what the House proposed and in no way improves upon the Affordable Care Act (ACA). In reality, this Act is irredeemable.

If the Better Care Reconciliation Act becomes law, tens of millions will lose insurance. A critical part of what they’ll lose is access to the care they need to prevent or manage chronic conditions in a life- and cost-saving way. More than 80 percent of the $3 trillion dollars we spend every year on healthcare goes to individuals with one or more chronic conditions—with better preventive care and well managed chronic disease clinical services we can reduce costs and improve health outcomes.

A better way for Congress to cut healthcare costs and keep Americans healthy would be to create legislation that increases investments in preventive services and programs and ensures people have access to clinical care before they develop costly conditions.

This bill does the absolute opposite.

In addition to millions losing insurance, the Senate bill would eliminate the Prevention and Public Health Fund beginning next fiscal year, which supplies 12 percent of the budget (or close to $900 million) for the Centers for Disease Control and Prevention (CDC). And, $625 million of that goes directly to states and communities to address their most pressing health needs, including drug misuse, infectious diseases, lead poisoning, obesity, diabetes, hypertension, cancer and tobacco use.

In addition, with the phasing out of Medicaid expansion and possible loss of guaranteed essential health benefits, effective preventive services—including vaccines and screenings for cancer—will no longer be required of insurers.

If the Better Care Reconciliation Act becomes law, the American people will be sicker and poorer. We will likely see more overdoses and untreated STDs, rises in infant mortality and increases in innumerable other preventable health issues, all of which add up to ever-increasing healthcare costs.

We strongly urge the United States Congress to start over and create a true healthcare bill that will actually improve the ACA and the nation’s health.”

Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority.

Public Health Leaders Make Urgent Joint Call to Protect Prevention and Healthcare

Joint Statement from American Public Health Association, Prevention Institute, Public Health Institute and Trust for America’s Health

June 20, 2017

The fight to protect public health is more important than ever.

The Senate is moving quickly—and secretively—on their version of legislation to repeal the Affordable Care Act (ACA). While we don’t know the content of the bill, we do know that the House-passed repeal bill—the American Health Care Act—would cause over 23 million people to lose their healthcare, restructure Medicaid, pare down essential benefits like maternity and newborn care, result in the loss of over a million American jobs, and zero out the Prevention and Public Health Fund. As leaders of organizations dedicated to protecting and advancing the public’s health, we call on Congress now to protect federal investments in public health funding, the Prevention and Public Health Fund, and affordable, high-quality healthcare.

Public health is at the very core of keeping our country safe, healthy, resilient, and secure. It works behind the scenes to ensure we have clean water to drink, safe food to eat, and healthy air to breathe. It works to safeguard us from infectious diseases like measles or Ebola by preventing the onset or spread of disease. It builds on time tested strategies to reduce the toll of chronic diseases and injuries. Public health works to redress long-standing inequities in health and safety, by investing in communities of greatest need. Through prevention, evidence-based treatment of substance use, prescription drug monitoring, and improved opioid prescribing, public health can solve the opioid epidemic, which kills ninety-one Americans a day. From opioid overdoses to rising infant and maternal mortality rates, Americans are seeing both the length and quality of their lives decline—and we need more, not fewer, investments in public health to turn the tide.

Repealing the ACA and its investments in public health and prevention dismantles the capacity of public health to do its work. The pain will be felt in every state, every congressional district, and every neighborhood, and those who are most vulnerable will suffer the most. If the Prevention Fund is eliminated, over the next five years states stand to lose over $3 billion they rely on to prevent chronic disease, halt the spread of infections, and invest in the community resources that support health and safety. Repealing the ACA and the Prevention Fund ensures there is no progress to reduce healthcare spending or improve the health of our workforce. Repealing the ACA will result in an America where preventable suffering and death are more widespread, and an America where the poorest and sickest communities fall even farther behind.

A strong public health infrastructure is at the very core of making our country safe, healthy, and secure. We need to act now to protect it.

The President’s FY 2018 Budget Proposal Would be Perilous for the Nation’s Health

Washington, D.C., May 23, 2017 – The below is a statement from John Auerbach, president and CEO, of Trust for America’s Health (TFAH) on the President’s Fiscal Year (FY) 2018 proposed budget announcement.

“The proposed $1.2 billion cut to the Centers for Disease Control and Prevention (CDC) would be perilous for the health of the American people.

From Ebola to Zika to opioid misuse to diabetes to heart disease, the CDC is on the frontlines keeping Americans healthy. Cutting nearly 20 percent of the CDC’s Chronic Disease Prevention and Health Promotion center’s budget would be disastrous.

Enormous cuts are also proposed throughout the rest of the agency including to programs that protect the American people from infectious diseases, environmental contaminants, exposure to tobacco and much more. If these budget cuts were to occur, they would cripple CDC’s operations and result in increased illnesses, injuries and preventable deaths.

CDC has already lost more than $580 million in funding since 2010 – and the proposed American Healthcare Act would, in FY 2019, repeal the Prevention and Public Health Fund, which supplies 12 percent of CDC’s budget—of which more than $620 million goes yearly to states.

Even now, with a relatively stable FY 2017 budget, CDC is operating with nearly 700 vacancies and will function with diminished resources once the Zika emergency supplemental funding runs out.

As such, this unprecedented and dramatic cut would have unparalleled and drastic consequences for our nation’s health and would likely lead to staggering increases in our healthcare service costs. It would also create massive holes in state public health funding, as states and local communities rely on the hundreds of millions they receive from CDC every year.

In essence, the proposed budget would force CDC to fight epidemics and health threats with both hands tied behind their back while wearing a blindfold.

We urge the Administration and Congress to work together to ensure CDC is able to protect the American people and help Americans be healthy and thrive.”

 

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Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority.

House ACA Replacement will Cripple the Nation’s Health, Trust for America’s Health Statement

Washington, D.C., May 4, 2017 – The below is a statement from John Auerbach, president and CEO, of Trust for America’s Health (TFAH).

“As historic as the passage of the Affordable Care Act was, any passage of the American Health Care Act will be just as infamous.

Tens of millions of American citizens will lose coverage. And millions of people on private insurance and Medicaid may lose access to life- and cost-saving clinical preventive services.

In particular, the Meadows-MacArthur Amendment would permit states to eliminate the requirement around essential health benefits (EHBs) and allow for the discrimination of people with pre-existing conditions.

Research tells us time and again two truths: Americans with coverage of preventive services are more likely to access these services and investing in preventive services improves health and reduces costs, yielding massive returns on investment.

Additionally, the agencies responsible for keeping us safe daily from ever-increasing public health threats will have their budgets slashed.

If the bill eventually becomes law, the Centers for Disease Control and Prevention (CDC) will lose 12 percent of its budget, of which a significant portion—$625 million a year—goes directly to state and local health departments.

This is a double whammy to the nation’s health.

Every day, the CDC and local public health departments are on the front lines in preventing disease outbreaks like Zika and Ebola, in protecting our children from lead poisoning, in lowering rates of heart disease, in stopping epidemics like prescription drug misuse and in helping people quit tobacco.

If the bill eventually passes, the results won’t be celebrated—they’ll be infamous.

We will likely see more overdoses and untreated STDs, rises in infant mortality and increases in innumerable other preventable health issues—not to mention mounting healthcare costs. All the while, our most vulnerable—the elderly, children, sick and less advantaged—will be at most risk.

That should not be the result of a health law.

We hope the United States Senate sees the many problems in the legislation.”

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Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority.