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Alternative Financing Mechanisms: Exploring Options for Healthy Homes Services

The National Center for Healthy Housing (NCHH) is a “go-to” resource for practitioners in the housing as healthcare industry. We get inquiries regularly: “Where is this being done? By whom and how?” We also look at the industry landscape ourselves and ask the same questions.

As we looked at the landscape in 2015, we closely reviewed the robust evidence base about the potential for transforming health outcomes and reducing healthcare costs by incorporating home-based interventions into patient care. Such interventions target social determinants of health, and investing in them has the potential to reduce the burden of preventable housing-related illness dramatically. The investing bit caught our attention, because we heard two conflicting scenarios.

On the one hand were states or individual managed care organizations providing Medicaid coverage for services delivered in the home environment related to asthma and lead exposure. On the other hand were states that indicated an interest in delivering home environment services but had not yet achieved Medicaid coverage. It seemed like their only option was to wait for Medicaid expansion coverage. But was it? As these conversations continued, we were aware of some states utilizing other financing mechanisms as either a complement or alternative to healthcare financing. The inevitable a-ha moment happened, and a series of questions followed: “What if more people know about these alternative financing mechanisms being used by certain states?” “Can someone, somewhere adopt an existing model as-is or with some modification?” “Is there a chance to increase the number of people receiving home environment services around the country?” We liked all the positive answers to these questions, and what followed was the alternative financing mechanism information project – after we secured funding from the W.K. Kellogg Foundation, of course. (Yes, our ideas depend on funding to be actualized.)

In 2016, NCHH interviewed several states providing one or more home-based asthma services, childhood lead services, or healthy home services using funding other than Medicaid or grants. The interviews provided information on the funding mechanism and how it operates, the program being funded and how it operates, outcome and evaluation information (where available), and lessons learned. We are pleased to share our findings of 12 different financing mechanisms.

This project does several things, but I would like to highlight one major feature—the “behind-the-scenes” information that the interviews provide.

The Montana Asthma Home Visiting Program (MAP) website tells us about the program. It is the interview that lets us know that not only does the program receive funding from the Master Settlement Agreement (MSA), it began to receive funding in 2007, nine years after the MSA accord was reached! This implies that even if MSA funds have not been a source for home-based asthma services or lead-based follow-up services, it is a potential source. Who else can begin to receive funding from their state’s MSA for home environment services?

One of the Massachusetts program interviews tells us how a trade-off was instrumental to raising funds for the program. The state amended the lead law to remove liability from organizations, and as a trade-off they accepted “surcharge on fees assessed by certain boards of registration, or state agencies for the licensure or certification of certain professionals, and on fees assessed for the renewal of such licensure or certification.” These surcharges raise about $2.5 million annually for Massachusetts Lead Education Trust Fund, income that would otherwise have been unavailable to support lead education services in the state!

The Maine interviewee spoke about the need to make the distinction between primary and secondary prevention. Just like several other states, Maine had a secondary prevention program. But secondary prevention only reacts after the fact. With the Lead Poisoning Prevention Fund, Maine now tests homes not just after a child has been poisoned in it, but before poisoning can happen to prevent poisoning.

Here are two things that stand out from the New Jersey’s project ReHEET interview: One, you can start where you are: Although they have received funding as high as $480,000, they have also worked with funding as low as $80,707! They began work with a few units. Two, the interviewee also pointed out how addressing more than one issue when intervening in a home lowers cost. They are committed to promoting energy and weatherization services to be incorporated with healthy homes services as a total package. Was someone thinking this might be a good idea? It is. They are working with it in New Jersey.

The page includes many more insights from our interviewees. For practitioners, we hope you are thinking “If them, why not us?” That’s what we are thinking too. Unhealthy homes are costing our nation too much in lost school and work days, medical expenses, and reduced quality of life. We encourage states and nonprofits to continue exploring alternate financing mechanisms that can support implementing evidence-based interventions for healthy homes.

Visit NCHH's Alternative Financing Mechanisms page here. Visit NCHH's Healthcare Financing page here.

Dr. Lillian Agbeyegbe is a public health practitioner with over a decade of experience in program development, implementation, and evaluation. As a project manager, she leads and supports NCHH’s Housing as Healthcare portfolio by developing resources, training, and providing technical assistance to support states in providing healthy home services.

The Silent Killer

No one heard the door open or a window shatter. Nobody saw a figure enter the small, darkened one-story home at the corner of Antioch Avenue in a slumbering Maryland neighborhood. There were no shouts, screams, or cries for help; the killer was silent, efficient, and dispassionate. And after the deed was done, the faceless killer simply vanished, virtually into thin air. By the time the sun rose the following morning, a single father and seven children were dead. There were no signs of entry and no fingerprints, footprints, or tire marks to assist the police. But there was one critical piece of evidence that helped the authorities to identify the killer: A portable gas-powered generator was discovered inside the home, its gas tank now empty....

And who did it? Carbon monoxide, often called "the silent killer."

It almost sounds like the premise for a horror movie, but that was a true story. The tragedy occurred in April 2015 in a small community on Maryland’s Eastern Shore, roughly 20 minutes from Salisbury University. Rodney Todd had separated from his wife a few years back, and the now-single dad was trying his best to keep the lights on and the food on the table for his seven children. He was committed to keeping his children, ranging in age from six to 15 years, happy, healthy, and safe. But his income from a dining services job at the University of Maryland Eastern Shore campus wasn’t enough to cover their living expenses. With no electrical service to his home, Mr. Todd installed a portable gas-powered generator to keep the lights and heat functioning through the cold nights.

What Mr. Todd didn’t know or understand was that he’d installed a combustion device in his home, and any stove, heater, lantern, or lamp that burns gas or oil fuel releases carbon monoxide (CO) into the air. Carbon monoxide is colorless, tasteless, and odorless, and it can kill you. You can breathe it in while sleeping or while talking to a friend or family member without realizing that you’re being poisoned, and it only takes a few minutes of exposure to be affected. If you’re awake, you may feel light-headed or weak, eventually experience flu-like symptoms, such as weakness, vertigo or dizziness, stomach upset or vomiting, or chest pain. If you’re asleep (or even inebriated, for that matter), you may not even notice these symptoms at all; you simply don’t wake up the next morning for work or school. Or anything ever again. Just like that.

Unfortunately, Rodney Todd’s story is not an isolated incident. On February 21 of last year, Leonard and Heather Quasarano and their four children, ranging in age from 23 months to 11 years, perished inside their two-story home in Fenton Township, Michigan. Their power went out, so the Quasaranos set up his gas-powered generator in the basement to keep the family comfortable as they slept, a fatal mistake. Said Genesee County Sheriff Robert Pickell, "It's very difficult just talking to the undersheriff who was in the house and saw all the bodies in the different rooms," he said. "No matter how long, how many investigations we conduct, seeing young children, an entire family wiped out, is just a very, very sad thing."

According to the U.S. Centers for Disease Control and Prevention (CDC), unintentional CO poisoning (non-fire-related) results in 20,000 emergency room visits, 4,000 hospitalizations, and roughly 300 fatalities every year in the U.S. The U.S. Consumer Product Safety Commission’s estimate (200 non-fire-related fatalities yearly) is more conservative but still tragic, especially when it happens to someone you know.

But you don’t have to die from CO poisoning to be affected by it. Even what some might describe as a “low-level,” nonfatal CO exposure may still result in permanent organ or brain damage. You may also suffer other side effects, such as headaches, amnesia, loss of muscle control, incontinence, and personality changes. These are usually short-term problems for most victims, but they can be permanent in some cases.

So how do you defend yourself and your family against a villain who can’t be seen, heard, smelled, or touched? What extra steps could Rodney Todd have taken to protect himself and the seven children who occupied that small house on Antioch Avenue? Are you making the same mistakes? How long before your luck runs out?

While there are many things you can do to reduce the likelihood of CO poisoning, let's focus on two solutions that might’ve saved Mr. Todd and his family.

First, avoid running any kind of combustion device inside your home. Read the instructions and heed the warning labels. If you must use a combustion device indoors, make sure that you have adequate ventilation. “Adequate ventilation” means that there must be some source of fresh air nearby, usually an open window or door. The window can be open only a few inches, but you must provide a way for fresh air to enter your home so that oxygen binds with the CO molecules, which creates carbon dioxide (CO2) instead.

Second, install CO alarms (also “monitor” or “detector”) in your home, if they aren’t there already. According to NCHH's National Healthy Housing Standard, a CO alarm is “an electronic device that measures the level of carbon monoxide gas… [and] … activates an audible alarm when an amount … above the device’s threshold level accumulates in the area in which the alarm is located.” The alarms look very much like a smoke detector and work similarly. The International Fire Code requires (and the Consumer Product Safety Commission also recommends) smoke and CO alarm models that include a voice notification system. There should be one CO alarm on each floor and outside each sleeping area, near the bedroom. NCHH is promoting CO alarm requirements as a safety provision in the National Healthy Housing Standard. Maryland (where NCHH is located) requires that homes constructed after January 1, 2008, have a hardwired CO alarm; some states have similar laws. Last year, NCHH proposed an amendment before the International Code Council that would require CO alarms in all properties governed under the International Property Maintenance Code (IPMC). ICC codes currently require only that CO alarms be installed in new structures and in existing properties where a building permit has been requested for renovations. Such an amendment would result in CO alarms being as prevalent in properties as smoke detectors, which we feel is extremely important for public safety.

Since most older homes have no CO alarms, that’s where you come in. If your budget is tight, you can buy a CO alarm for under $20; units with more bells and whistles, such as models that also detect smoke or explosive gases, cost more but are still affordable; and they’re a small price to pay for peace of mind. You can even buy a “travel alarm,” which is not a bad thing to have with you on a trip, because you’ll never know when you’ll need one.

If your CO detector runs on batteries, be sure to replace them twice per year. You should install new batteries when you change the time on your clocks each spring and fall, just as you do with your smoke alarms. You were already doing that, right?

Great, you've installed the CO detector! That's your best tool for protecting your family and yourself, although there are several other ways to minimize the threat of CO poisoning. For example, when shopping for appliances or equipment, be sure to look for products that have been approved by a nationally recognized testing lab, such as UL or NSF International. Make sure that any gas appliances are vented properly, with horizontal vent pipes angling slightly upward. Have a qualified service technician inspect your heating system and combustion appliances annually, and, if you have a fireplace, get your chimney checked for blockages every year. Also, don't burn charcoal or use a portable gas camp stove or inside.

Now, let’s say your power's on, your furnace works just fine, and you don’t have a gas generator in your kitchen or living room. Are you still at risk for CO poisoning?

Yes, you may still be in danger. Here's another story: It was two days after Christmas when Melissa and Jorge were killed. They left their home in New Jersey on a frosty night to celebrate their anniversary at a charming little bed and breakfast in Stroudsburg, Pennsylvania, laughing and joking flirtatiously. The happy couple pulled off the road and parked for a moment in front of a strip of storage garages. Melissa had a key. Should they or shouldn't they? Melissa opened the door to garage 55. They backed in, and Jorge shut the door. They needed a little privacy, just for a few minutes; then they'd be back on the road. But they never saw the killer that entered the garage with them...

Most CO exposures occur inside the home, but there are far too many incidences of accidental exposures and deaths relating to car exhaust fumes wafting into the living areas of homes and poisoning families. Some are unusual, such as the case of the man who committed suicide in his garage but inadvertently killed his wife and two daughters as they tried to rescue him, that tale of the amorous New Jersey couple who lingered in their car too long, or the tale of heroic father who realized that his car had been idling and opened the garage door, preventing the deaths of his family and their neighbors but not his own—he collapsed and died before he could shut off the car’s ignition, a shocking reminder of how quickly carbon monoxide can overcome a person; but most of the stories are just sad. And all of these tragedies could have been avoided if only the victims had known that about the silent killer that is carbon monoxide.

Now that you know what to do and what not to do, be safe and sleep peacefully.

Decorating for the Holidays: How to Hang Your Lights Safely This Year

Jingle all the the ER? According to the Consumer Product Safety Commission, there are about 12,000 or more reported emergencies involving holiday lighting each year. But that’s certainly not what you want to be thinking about when you’re gathered round the tree.

The best present you can give yourself this year is a little peace of mind. And that’s not too hard to do when you follow best practices for seasonal lighting. With the proper equipment and lighting techniques, you can avoid a holiday disaster, and still get the most beautiful lights on the block.

Replace Incandescent String Lights with LEDs

LED lights usually get promoted solely for their energy efficiency—but they also run much cooler than incandescent lights, as well. In consumer testing, LEDs ran over 200 degrees cooler than comparable incandescent lights, a trend that translates over to your seasonal decorations, as well. Cooler lights means less danger for combustion, so LEDs are typically considered safer than their incandescent counterparts.

Of course, simply purchasing LED lights can’t root out every problem. You also need to make sure you use safe practices with extension cords and outlets, as well. But they can certainly eliminate some of the risks associated with decorating—which is definitely one way to make things merry and bright!

Use Caution When Hanging Exterior Lights

We’ve all seen the damage that can come from improper lighting techniques (if not, stop reading this article, watch National Lampoon’s Christmas Vacation, and come back). However, unlike in the realm of fiction, accidents here can result in serious injuries that are nothing to laugh about.

If you’re hanging lights high, make sure that you have a sturdy ladder, and stand it on even ground. Move the ladder as you go instead of reaching too far to your left or your right. Invest in a set of light holders rather than using nails or a staple gun—and give yourself some extra cookies for being smarter than Clark Griswold.

Look Your Lights Over

A lot can happen in a year while lights are stored away in the attic. Make sure to give every strand a visual inspection—and don’t chance it with frayed or damaged lights.

Plug string lights in before hanging them. If they don’t light up, then they’re no good to you anyway, and it will save you the hassle of hanging your lights, only to have to take them all down again. And who needs that wasted time during this busy season?

Use the Proper Lights, Cords, and Outlets

Minus the right equipment, even the most magical light display can go sour fast. If you’re putting lights outdoors this year, make sure both the lights and any extension cords you use are rated for exterior use. Lights should be waterproof, as well, to protect them from wintry weather. Also, check that your cords are UL-approved—this independent consumer safety group tests commercial electrical products to verify their safety.

Outlets, too, need to be chosen with safety in mind. Install lights on a ground fault circuit interrupter (GFCI) outlet. As the name suggests, this kind of outlet will interrupt the electrical circuit if the outlet becomes overloaded. Obviously, you should avoid plugging too many different lights into the same outlet, as well, but this will help you avoid sparks if you happen to go overboard.

With some lighting smarts, the only fires you’ll be seeing this year will be for those roasting chestnuts! Wishing you and your family a happy and safe holiday!


Erin Vaughan is a blogger, gardener, and aspiring homeowner. She currently resides in Austin, TX, where she writes full time for Modernize with the goal of empowering homeowners with the expert guidance and educational tools they need to take on big home projects with confidence.

The Family that Smokes Together (Expanded)

Before Dad was a physician, he was a smoker. And, because we lived in his house, we were smokers too.

Throughout my life, people have thought it odd that a doctor could also smoke, but it’s not really so strange because Dad started his habit at 14. Smoking was one of the things people did back then, all the time—at home, at work, at parties. Millions of soldiers received free cigarettes during World War II, and when they returned home from the war, they were hailed as heroes, role models for kids everywhere. And our heroes smoked.

My father was already a veteran of smoking before he ever set foot in med school, and any doctor will tell you that med school is incredibly stressful—it’s not the best environment for quitting anything, except maybe sleep. Plus, he enjoyed it. These were the days before the Surgeon General’s package warnings, the terrifying ads, and the lawsuits. By 1966, when the warnings started appearing on cigarette packaging, he’d already spent half of his time on Earth as a smoker.

As kids, my sister and I waged a failing war against the cigarettes: We begged and pleaded, we pinched our noses and complained about the horrible smell. We hid the packs and the ashtrays. I’ll bet many of you did the same things to your parents. One time I even “loaded” a cigarette, which resulted in a small explosion that angered Dad, not because he was surprised by it but because the cinders nearly burned his shirt. But every time we tried, he proved that his love of smoking was somehow stronger than we were.

Our success—such as it was—was comparable to everyone else who battled smoking at that time. Public policy (most notably, the 1964 Surgeon General’s report, which linked smoking to lung cancer) managed to curb smoking’s stratospheric popularity, but it didn’t result in a massive reduction in the overall quantity of smokers. By the mid-1970s, the anti-smoking movement was highly visible, and the number of smokers fell incrementally.

Dad eventually responded to our protests smoked by switching to a pipe for a year or so. He looked very distinguished, and the pipe smoke smelled better than that of the cigarettes; but it was still smoke that wafted through the halls.

So we grew up with smoke in the house every morning before, during, and after breakfast. Some people wake up to the aroma of eggs or bacon, but we woke to the acrid odor of cigarettes. The other thing I woke up to almost without fail was a lump in the back of my throat—an actual lump of gunk that accumulated there while I slept. Part of my morning routine was to get up and expel a gob of phlegm into the sink. It didn’t end there, either—several times a day I repeated this ritual, right up until bedtime. Every day, for years.

My mother thought it was disgusting, and she told me so. I agreed, but what was I supposed to do about it? “I gotta get it out somehow,” I muttered grimly as I continued to hack away.

Now, you’d think from this description that my house was absolutely hazy with smoke all the time, but it wasn’t. Dad had very long hours throughout the week and when he was away, we didn’t notice any lingering smell.

Something unexpected happened when I left for college. Within a few weeks, my coughing subsided. A few more, and it ended altogether. Honestly, I hadn’t noticed it happening, probably because it was so gradual and because I hadn’t made any conscious changes to my lifestyle. I only noticed it when I woke up on the first full day of my fall break. The lump in my throat was back, which must’ve meant that it had stopped sometime while I was away. My mother heard me and commented again about the horrible noise and what a disgusting habit it was. I told her that no one was more disgusted by it than I, but it was funny because this morning was the first time I’d done it in a long time—there must be something in the house that was making me sick.

It wasn’t long after that I started hearing about the dangers of secondhand smoke. Secondhand smoke is the smoke that the other people in the presence of a smoker breathe, the smoke that my father expelled from his lungs after every drag from his cigarettes or puff from his pipe as well as the smoke that rises from these tobacco products as they burn. In short, it’s what my sister and I complained about for roughly 20 years. All the things that can happen to a person as a result of smoking can happen to a nonsmoker too if they’re exposed to secondhand smoke. Secondhand smoke is a known trigger for people with asthma and can lead to lung cancer, too.

You may not have heard of it, but there’s also a thing called “third hand smoke,” which is the chemical residue left behind on surfaces that we take into our bodies by touching contaminated surfaces, ingest from hand-to-mouth contact (or possibly via our food), or breathe in as dust after the actual smoking stops. These would be the chemicals trapped in curtains, on wallpaper or painted surfaces, or the foul odor you detect in a smoker’s car. Whatever you smell in the car is the particulate residue of various chemicals including carbon monoxide, arsenic, butane, lead, toluene, and hydrogen cyanide. If you’ve spent any time on our website at all, you may already know how dangerous carbon monoxide and lead are. Butane is used in lighter fluid and  fuel for camping stoves, and toluene is found in paint thinner. Anything with a name like “hydrogen cyanide” can’t possibly be good for you; this substance is used in chemical weapons. If that’s not frightening enough, polonium-210 is a radioactive carcinogen (meaning it can cause cancer). And arsenic is, well, arsenic. That’s what you’re taking into your lungs when you’re breathing second- and third hand smoke. And before you say anything about air fresheners, forget it: They’re masking the chemical smell, not removing it; you’re still breathing smoke residue and to it you’ve added other chemicals blended to smell like pine or vanilla.

Despite our efforts, our family was never able to convince Dad to quit, although he did smoke less in his later years—a minor victory that may have actually had more to do with changes in public policy. State and federal government have raised taxes substantially over the last twenty years, and laws now prohibit smoking inside or near entrances to almost all public buildings and many public parks, on planes, or on buses. Smoking is now a very expensive habit, and it’s hard to find anywhere to do it outside of your own personal property. As if to follow their lead, my mother—herself a former smoker—insisted that our father’s was no longer allowed to smoke in the house. In the winter, he was allowed to use the garage. Stubbornly, he persisted through the rain and the snow. After all, it was his life, and he wasn’t going to quit just because someone said he should.

And that’s what I say to you: Sure, it’s your life—you can do what you like with it, but what about your family and your friends? Are their lives yours too? And what about your pets? Does old Rufus have to suffer because you don’t feel like quitting? He might be “man’s best friend” to you, but if he knew what you were doing to him, he might not hold you in the same regard. So, if you're a smoker, why not quit? If not for yourself, then how about for your family? And if you’re not willing, or haven’t been able to break the habit, at least take it outside.

As for my own Dad, well, he finally did stop. It happened after he spent a month on the ventilator after a surgery, a procedure that followed angioplasty and an open-heart bypass. His lungs were really weak. When he finally left the hospital, roughly 20 days later than expected, he realized that he was never going to wake up from the next surgery at all if he kept smoking. All of the surgeries he'd endured might've been avoided had he not smoked or even if he’d quit sooner. Suddenly, smoking seemed to be a lot less enjoyable to him, and so he quit—at age 60—but he’d done too much damage to his body. He was already suffering from emphysema by then and often used an oxygen pump to assist his breathing. Still, I think quitting did allow him to live a longer life, and he got to meet his first grandchild before he passed.

This is an expanded version of a blog post that first appeared on in September 2016.

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 for more information or check out our new state-specific case studies and other resources in our Healthcare Financing Resource Library.

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