Delivery of Care

Is this as good as it gets for children?

Successes achieved in children’s health over two decades in Rhode Island may now be in jeopardy

Photo courtesy of Rhode Island Kids Count, Peter Goldberg photo

Gov. Gina Raimondo speaking at the 2016 Rhode Island Kids Count luncheon celebrating children's health in Rhode Island. She will again be speaking at the 2017 luncheon scheduled for Monday, Nov. 6.

By Richard Asinof
Posted 11/6/17
The 17th annual Rhode Island Kids Count lunch celebrating children’s health in Rhode Island demonstrates what committed community advocates working in collaboration with elected officials can accomplish. It also reflects what can be lost as a result of Trump administration policies and a Republican-dominated Congress. The efforts to eliminate childhood lead poisoning offer an imperative argument to improve educational achievement, economic attainment, and improved public health outcomes.
In the upcoming 2018 governor’s race, which candidates, if any, will actively campaign as a champion for children’s health? In the face of federal cutbacks, will there be any appetite to increase funding for health insurance coverage for low-income women and children? When will the issues of economic stress become part of the discussion around the epidemic of overdose deaths, including alcohol and suicide mortality? When will efforts to improve third-grade reading scores incorporate efforts to eliminate childhood lead poisoning as an integral component?
The success of Rhode Island Kids Count has been predicated upon a rich database of evidence and facts to persuade elected officials to be champions of improving children’s health and education in Rhode Island. As part of that approach, advocacy efforts have chosen to accentuate the positive in building constructive relationships.
With the ascension of President Donald Trump and the politics of division, where facts do not seem to matter, that environment where reasoned and reasonable arguments can achieve political compromise has been eviscerated.
In addition, the faith in the leadership of government officials to do the right thing has been eroded by the failure of the UHIP launch, the continuing crisis at DCYF, the growing epidemic of overdose deaths, and the financial breakdown of the hospital-led health delivery system. Outrage reigns.
In such a polarized world, does it require a new kind of political strategy to succeed?

PROVIDENCE – On Monday, Nov. 6, when Rhode Island Kids Count holds its 17th annual luncheon celebrating the positive health outcomes achieved for children in Rhode Island, attended by more than 200 community leaders, elected officials and health care advocates, there may need to be an asterisk attached.

Because many of the 2016 achievements to be hailed at the luncheon may capture, in a kind of memorable screen shot, the apex of the curve, as Trump administration policies and inaction by the Republican-controlled Congress begin to take effect and precipitate a sharp decline in children’s health outcomes.

For instance, much of the success in health outcomes for children in Rhode Island, including ranking third in the nation for the highest rate of health insurance coverage for children, with 98.1 percent of all Rhode Island children under the age of 18 covered, is a result of the federal Children’s Health Insurance Program, or CHIP, which provided funding for low-cost health insurance for 9 million kids nationwide.

That is right: provided, in the past tense. Congress let the bipartisan CHIP program expire as of Oct. 1, 2017, and there are no plans on the horizon by the Republican-controlled House or Senate or President Donald Trump’s administration to make its reauthorization a priority. Those funds in Rhode Island are expected to run out early in 2018.

Translated, as a result, many of those 9 million children and their families will be getting a lump of coal in their stockings as a Christmas present: no federal funds to support low-cost health insurance.

In addition, the future funding for RIte Care, the managed Medicaid program for low-come families and their children in Rhode Island, is targeted for major cutbacks under the Trump budget and tax reform plans.

At last year’s luncheon, held a week after the election of President Donald Trump, the data presented by Rhode Island Kids Count showed that in Rhode Island for 2016:

RIte Care health plans received top ratings when compared to Medicaid health plans in the U.S.; 93 percent of pregnant women received timely prenatal care; and some 95,737 children, 45 percent of all children under the age of 18 were enrolled in RIte Smiles, in the companion program for dental care.

Also in play is the looming state budget deficit projected for Rhode Island in the coming year, during a gubernatorial election. Republican candidate for Governor, Rep. Patricia Morgan, for instance, wants to reduce the number of services that health insurers are mandated to cover in Rhode Island, according to WPRI’s Ted Nesi.

With diminished funding for health care from the federal government and little appetite at the State House to increase funding for health and social services, the likelihood is cuts in spending may be made to the state’s Medicaid budget.

The question is: at next year’s Rhode Island Kids Count luncheon, what kinds of declines will the data show for 2017 and 2018?

Accentuating the positive
At the luncheon, Rhode Island Kids Count will present “Covering Kids Awards” to elected officials for their efforts to increase access to health insurance coverage. Those to be honored this year include:

Gov. Gina Raimondo, Sen. Jack Reed, Congressman Jim Langevin, Congressman David Cicilline, Rep. Marvin Abney, chair of the House Finance Committee, and Sen. Josh Miller, chair of the Senate Health and Human Services Committee.

In addition, Samara Viner-Brown of the R.I. Department of Health and Carrie Bridges Feliz of Lifespan’s Community Health Services will also be honored as community partners in ensuring that children have primary health and dental care.

Two families are also slated to share their perspective as RIte Care members.

Good news on the lead poisoning prevention frontlines
The Childhood Lead Action Project received a $30,000 EPA Environmental Justice Small Grant award in support of its initiative, “Lead-Safe Blackstone Valley,” which will work to reduce the incidence of childhood lead poisoning, improve the safety of rental housing and increase the capacity of residents of Central Falls, Pawtucket and Woonsocket to address lead issues in their communities.

The three cities have a high incidence of lead poisoning and they are home to substantial low-income and minority populations, according the news release issued by EPA.

The Childhood Lead Action Project will celebrate its 25th anniversary on Thursday evening, Nov. 16, at the Crowne Plaza in Warwick, honoring the organization’s founding executive director, Roberta Hazen Aaronson.

Economic health disparities
The recent Nov. 3 edition of the student-run publication, Brown Political Review, featured an article, “A Poisoned Well: Rhode Island’s Trouble with Lead,” written by Brown student Nathaniel Pettit.

Here are some excerpts from the article, which provides an economic framework to the public health issue of childhood lead poisoning: “Across American households, the inequality of [lead] exposure is the central injustice of this epidemic: It is a matter of opportunity, not just one of health.”

Pettit wrote: In her May 2017 National Bureau of Economic Research study, Anna Aizer, an economist at Brown University, published data on lead and juvenile delinquency among Rhode Island youth. The paper, coauthored by Janet Currie of Princeton University, is crucial in advancing the understanding of lead exposure as an issue of social justice and inequality of opportunity.

Aizer’s study capitalizes on a dataset of blood lead levels from the state’s robust screening program. Between 1990 and 2004, 120,000 children born in Rhode Island were tested at various stages of childhood development.

Aizer and Currie first note that low-income and minority children in the state are more likely to live in urban neighborhoods. Inhabitants of urban areas are more susceptible to lead exposure due to the greater likelihood of high traffic congestion and older housing, two major sources of lead pollution.

The study further confirms that the burden of lead exposure is disproportionately placed upon the shoulders of low-income people and people of color in Rhode Island, as is the case in many communities across the nation.

Pettit continued: Lead exposure is profoundly disruptive for children. For every unit increase in BLL [blood lead levels], the probability of school suspension increased from 6.4 to 9.3 percent. These disruptions correspond to academic deficits: An August 2016 study from Professors Aizer and Currie found that for every one unit increase in BLL, the probability of a student scoring substantially below proficiency in reading rose by 3.1 percentage points. Outside of the classroom, the effects are even worse: The researchers found the same increase in BLL augmented the likelihood of incarceration by up to 74 percent.

Elizabeth Tobin-Tyler, a lawyer and professor at Brown’s Alpert Medical School, emphasizes a central absurdity in how we approach lead poisoning: “Most of our systems are about what happens after a kid gets poisoned as opposed to creating systems and structures that ensure we are addressing the problem before the exposure happens.”

Indeed, the current way of dealing with lead is reactive, with action usually beginning after exposure in a child has been reported. Furthermore, systems generally place the burden on tenants to report possible lead hazards, intimidating would-be reporters by allowing the possibility of retributive eviction. The status quo thus forces low-income tenants to choose between adequate living standards and having a place to stay, often silencing the victims of lead exposure.

Lead in drinking water
Pettit also addressed the problems of lead in drinking water in Providence: Current regulations in the Ocean State have simply not gone far enough to address the problem. Providence Water, a department of the city, will replace lead lines from the water main to the curbs, but it is not allowed to use ratepayer funds to address lead pipes on private property, a system known as “partial pipe replacement.”

This leaves the onus of replacing lead pipes on property owners themselves. Particularly for those lacking the finances to personally pay for removal or renting from an unwilling landlord, this burden is often too high. Worse, as the neighborhood of Mount Hope in Providence discovered in 2010, this “partial pipe replacement” can exacerbate the problem: By disrupting the pipes and inadvertently exposing water to increased levels of lead, partial pipe replacement is often accompanied by spikes in lead levels in the short term.

Summoning the will to address these regulatory inadequacies has proven easier said than done. The first hurdle, unsurprisingly, is a financial one. Replacing a large service line containing lead costs between $2,000 and $3,000—meaning it would take about $95 million to replace the nearly 38,000 lead service lines owned by Providence Water, Rhode Island’s largest supplier. As of August 2017, Providence Water began offering a three-year, zero percent interest loan to homeowners in need of replacing lead service lines. However, even at such terms, the program remains inaccessible to thousands of low-income Rhode Islanders.

The economic equation
Pettit concludes with economic argument as a call to action on removing lead from the environment: To motivate action, then, politicians should look to the social benefits of removing lead. Research suggests that although the initial investment would be expensive, the ultimate social rewards—in the form of less crime, higher productivity, and lower medical costs—would be worth the price. Research from PEW Charitable Trusts explains that, across the country, removing lead service lines and eliminating lead paint from low-income homes with young children would see returns over time of about $1.33 per dollar invested.

The lead exposure debate here in Rhode Island and across the country requires elected officials to embrace short-term investment for a long-term reward—a difficult campaign platform for officials who might no longer be in office by the time society reaps the benefits. There is good reason for optimism, however, even in the face of this daunting task: The Aizer and Currie studies strongly suggest that reducing lead exposure would offer children greater impulse control, decreased rates of juvenile delinquency, and improved school performance.

While acknowledging that it comes with real costs, fixing the problems of lead should be seen as a safe investment in improving social outcomes for those whom our society most often fails. Eradicating lead exposure is an imperative task for a society intent on pursuing justice, and Providence might just be the place to start.

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