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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 the Clinical Professor and Director of the ChildLaw Policy Institute at Loyola University Chicago School of Law.

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.

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