By Colleen Corrigan, Peter Harbage Fellow
April 28, 2023
Top image via iStock from FatCamera
Asthma is the most common childhood chronic health condition, and in California, nearly 1.5 million children suffer from its effects. Children with asthma are more likely to miss school and be hospitalized for asthma-related events; over time, asthma can cause lung damage. Asthma’s burden on families with children highlights the importance of asthma remediation services, asthma prevention efforts, and indoor and outdoor air quality improvements.
Asthma and air pollution
Early exposure to outdoor air pollution—which comes from the burning of fossil fuels from car emissions, gas stoves, oil refineries, and industrial operations—affects children before they are even born. Exposure to high levels of a certain type of pollution (particulate matter) during pregnancy increases the risk of preterm birth and reduces lung volume and lung function in infants. Certain air pollutants can activate stress responses and release hormones like cortisol, which severely inhibit the healthy cognitive and physiological development of children. Lifetime exposure to air pollution can lead to heart and lung diseases, aggravate asthma and allergies, contribute to the onset of asthma in otherwise healthy people, and cause premature death.
Asthma is a racial equity and environmental justice issue as much as it is a health concern. The burden of air pollution disproportionately falls on communities of color because, for example, hazardous waste sites and the US interstate highway system were constructed largely in Black and Brown neighborhoods in the 1950s. Black children are exposed to air pollution more often than white children; they are twice as likely to have asthma and four times as likely to die from it. According to the American Lung Association’s 2023 “State of the Air” report, California is home to ten of the 25 most-polluted cities, continuing its record as the most polluted state since 1999. Common asthma triggers include secondhand smoke, dust mites, outdoor air pollution (e.g. factories, wildfire smoke, and traffic), pests like cockroaches or mice, pets, mold, and harmful disinfectants or fragrances. A recent study highlighted that approximately 12.7% of childhood asthma can be attributed to gas stove pollution. There is no statewide or federal regulation to prohibit gas stoves, but California is pushing towards limiting the use of natural gas, and a new Medi-Cal program—Asthma Remediation—include installing exhaust fans for stoves.
Asthma Remediation, a new option under the Community Supports program, is currently offered by 78% of Medi-Cal health plans. It provides asthma trigger remediation supplies and services like mold removal, ventilation improvements, air purifiers, and dust-proof pillowcase covers for Medi-Cal enrollees with poorly asthma as part of the state’s multi-year CalAIM reform initiative. The Asthma Remediation option is paired with a new Asthma Preventive Services policy which went into effect in July 2022. The new benefit offers clinic- and home-based asthma self-management education for any beneficiary with a diagnosis of asthma, and in-home environmental trigger assessments for adults and children with poorly controlled asthma. These services can be provided by community health workers and promotoras. These two new Medi-Cal supports and policy successes are grounded in a three-year, $15 million investment from the California Department of Health Care Services (DHCS) in 2019 to implement the Asthma Mitigation Project (AMP), administered by The Center at Sierra Health Foundation and launched in 2020. Through grants from AMP, 28 local partners provide culturally and linguistically resonant asthma home visiting and remediation services to children and others with poorly controlled asthma in 41 counties throughout the state.
AMP has been shown to build home visiting workforce capacity and asthma service provider networks for community members with Medi-Cal or without health insurance. For example, the AMP Evaluation Report for Year Two highlighted improved asthma mitigation strategies, utilization of community resources, and feelings of empowerment for AMP participants, as shown by the following survey results:
While 97% of clients addressed some or most triggers during AMP, they also recognized broader systemic challenges. For instance, may clients noted landlord difficulties at times prevent full remediation efforts, and there’s little families and children can do about external environmental factors such as poor outdoor air quality from wildfires and climate change, difficulty in sustaining remediation, access to healthcare, and the ongoing COVID-19 pandemic. Because AMP rolled out during the pandemic when there was significant concern and reluctance about in-home visits, AMP grantees adapted to successfully provide virtual home-based asthma services. Other lessons from AMP include: the important role that medical providers play in connecting children and their families to services; the critical relationships needed with health plans to support the long-term sustainability of asthma prevention and remediation programs; and the need for additional capacity-building efforts that will help establish local relationships, healthcare collaborators, and training supports (e.g., the Asthma Management Academy (AsMA) at the California Department of Public Health (CDPH).
As part of a multi-year policy advocacy strategy, Children Now and its partners at Regional Asthma Management and Prevention (RAMP) and the California Pan-Ethnic Health Network (CPEHN) are at the forefront of efforts to educate medical providers and health plans about the value of partnering with asthma remediation programs and to sustain efforts started by AMP in the years ahead. (See a first-of-its-kind directory of asthma home visiting programs in California here.) The directory connects plans with local programs and provides information about asthma home visiting programs in California, including service areas and eligibility.
In addition to the ongoing CalAIM implementation, it is imperative the Medi-Cal Population Health Management program prioritizes addressing the root causes of asthma while continuing to invest creatively in remediation services for people with poorly controlled asthma. This includes addressing the quality of health care that Medi-Cal members receive. Less than two-thirds (64%) of Medi-Cal members with asthma had proper medication control, which is well below the statewide average of 81.7%. Overall, the economic costs of asthma in California are estimated at $11.3 billion per year in direct health care costs, lost work and school days, and lost productivity due to premature death; public programs like Medi-Cal are footing a lot of the health care costs (Medi-Cal and Medicare cover 65% of asthma hospitalizations and 50% of asthma emergency department visits in the state).
More importantly, asthma makes it difficult for children to exercise, play, and attend school—especially kids of color who are more likely to live in neighborhoods with environmental stressors.
We commend our Medi-Cal leaders at DHCS for their innovation, and recognize that many local partners and community health workers in communities across the state are working to improve health and well-being for families. There is still so much more to be done to improve air quality and asthma management. Childhood asthma is not just a health policy issue; it must be addressed by improving housing quality, mitigating transportation and agricultural air pollution, and transitioning to a cleaner and safer environment for families and communities.