State Category: Maryland

Maryland’s Efforts to Prevent and Respond to Childhood Lead Exposure

“Working with our partners, including Baltimore City and the Green & Healthy Homes Initiative, Maryland has made significant gains to protect our children, particularly those who live in older rental housing. But a significant number of lead poisoning cases in Maryland are linked to newer rental housing. The change in Maryland’s lead law will allow us to prevent more children from suffering the effects of lead poisoning. We cannot, and will not, let up in our work to eliminate childhood lead poisoning in our state.”- Robert M. Summers, Secretary, Maryland Department of the Environment

Background

The Maryland Department of the Environment’s (MDE) Lead Poisoning Prevention Program coordinates statewide efforts to reduce childhood lead poisoning including assuring compliance with Maryland’s Reduction of Lead Risk in Housing Act. The statute and associated regulations (Environmental Article 6-8) require owners of rental properties built before 1978 to annually register their properties with the Maryland Department of the Environment, comply with a lead paint risk reduction standard, and distribute tenant educational information (a Notice of Tenant’s Rights brochure, a lead education pamphlet about protecting one’s family from lead in the home, and a copy of the current lead inspection certificate for the property).

The law, as originally passed in 1994, was intended to make housing units safer for children and help prevent childhood lead poisoning. It was also intended to help rental property owners and managers avoid costly lead poisoning litigation by complying with registration requirements and specific lead hazard reduction and inspection certification procedures.

A legal challenge to the tort protection clauses resulted in the removal of the implementation of those liability protection provisions from the law in 2011.The law was modified in 2012 to include rental properties constructed prior to 1978 (whereas the original law was only mandatory for pre-1950 rental units and had been optional for 1950-1978 constructed units), a change motivated by a significant percentage of new childhood lead-poisoning cases in Maryland that were linked to homes built after 1949.

Registration and Risk Reduction Requirements

Owners of residential rental properties built before 1978 must register their properties annually with the Maryland Department of the Environment. They can complete registration online or via a paper form, and registration fees are $30 per unit. Registration is specific to ownership of a property and must match exactly what is on record with the Maryland Department of Assessments and Taxation. A change in ownership, including adding owners or changing to a corporation, requires a new registration and new tracking number.

Rental properties covered by the law must be free of chipping, peeling paint and lead contaminated dust. To qualify for registration, owners must hire a certified contractor to address any defective paint and have an accredited lead paint inspector verify compliance before any change in occupancy. Inspectors issue a lead paint risk reduction certificate for each dwelling unit that passes the inspection.

Whenever a tenant notifies an owner that there is defective paint or there is a child with an elevated blood lead level, the owner has 30 days to conduct modified risk reduction measures and pass lead inspection certification. The rental property owner is responsible for temporarily relocating the family to a lead-safe or lead-free dwelling while the original dwelling undergoes risk reduction measures.

Litigation Implications of the Law

The widespread and routine application of lead exclusions in general liability insurance policies covering rental units helped motivate the enactment of the lead law in 1994. The statute added provisions to the Maryland Insurance Code, which limited the circumstances under which these exclusions would be effective. The law limited tort damages when the property owner satisfied certain housing unit registration requirements and after the unit passed lead dust tests or underwent a set of risk reduction measures. It also offered the owner the option of making a “qualified offer” (a payment to provide compensation in the form of relocation and medical benefits to the child and his or her legal guardian) in lieu of litigation when a child developed an elevated blood lead level in a compliant property.

In 2011, the Court of Appeals of Maryland issued an opinion in Jackson v. Dackman Company that found the limited liability section of the law is unconstitutional. The court ruled that the possible remedies contained in the law were not adequate compensation for the potential harm to an injured child from lead poisoning. The court also found it was unreasonable for the law not to offer a child the ability to bring suit for his/her injuries after the child reaches the age of majority. The court ruled that the remaining provisions in the law could continue to be enforced.

Implementation of Strong Public and Private Enforcement

A key component in Maryland’s substantial decline in childhood lead poisoning has been its strong public enforcement of the Maryland Reduction of Lead Risk in Housing Act coupled with local enforcement coordination and private enforcement actions by non-profit agencies and pro se tenants.

MDE files 500 to 800 violation notices annually, and a team of four to five people from the state’s attorney general’s office is responsible for enforcing actions against non-compliant owners.

Another highly effective best practice has been MDE’s policy of pursuing enforcement against a rental property owner’s entire non-complaint housing portfolio once enforcement actions have been initiated against any one of the owner’s properties. Local housing code enforcement and landlord licensing officials at the city and county level also help coordinate enforcement by referring non-compliant properties in their jurisdictions to MDE for enforcement of the registration and risk reduction requirements.

To increase the law’s effectiveness, private enforcement through family advocate attorney representation from the Green & Healthy Homes Initiative and other non-profit legal services providers is utilized statewide to assist tenants in obtaining risk reduction certification of their units, temporary relocation during lead hazard remediation and the use of lead certified contractors. The passage of legislation to support the law’s implementation through private enforcement and the development of lead poisoning prevention resources include:

  • Permitting tenants to establish court ordered rent escrow accounts until lead hazards are remediated in their rental unit;
  • Denial of District Court rent court access for the collection of rent for non-compliant property owners until their property is brought into compliance;
  • Requiring that non-compliant rental property owners pay up to $2,500 in relocation benefits to assist tenants in permanently moving to a new, lead certified home; and
  • Creation of a lead preference for Housing Choice Vouchers that provides vouchers to permanently relocate families with lead poisoned children who reside in hazardous housing to lead certified housing.

Other Responsibilities of the Lead Poisoning Prevention Program

The Maryland Department of the Environment assures compliance with mandatory requirements for registration and lead risk reduction in rental units built before 1978; maintains a statewide listing of registered and inspected units; and provides a blood lead surveillance database of children tested in Maryland.

The Maryland Department of Health and Mental Hygiene oversees blood lead testing initiatives in the state. All children living in at-risk areas for lead poisoning or receiving medical assistance must be screened for lead poisoning at 12 and 24 months of age, with children between 24 months and six years old in these at-risk areas required to be screened if the child has not previously tested or if documentation cannot be verified. Maryland recently adopted universal blood lead testing for children under age 6 for a period of three years in order to better measure actual blood lead testing rates in Maryland and to assess the accuracy of the methodologies utilized in Maryland’s previous targeted testing plan.

The Maryland Department of the Environment’s Lead Poisoning Prevention Program is also responsible for:

  • Overseeing case management follow-up by local health departments for children with elevated blood levels;
  • Certifying and enforcing performance standards for inspectors, risk assessors, and abatement contractors;
  • Performing environmental investigations for lead-poisoned children; and
  • In cooperation with the Maryland Department of Health and Mental Hygiene, providing oversight for community education to parents, tenants, rental property owners, homeowners, and healthcare providers to enhance their role in lead poisoning prevention.

Results

Since the Maryland Reduction of Lead Risk in Housing Act’s enactment, the rate of high blood lead levels has declined by 98 percent in Maryland. In 1993, 14,564 children (23.9 percent) of the 60,912 children under 6 who were tested had blood lead levels of 10 µg/dl or higher. By 2015, that rate had declined to 377 children of the 110,217 children 0-72 months tested (0.3 percent) for blood lead in Maryland. The declines in percent of children with blood lead levels equal to or greater than 10 µg/dL and between 5-9 µg/dL in 2014 compared to 2013 were 4.6 percent and 10.8 percent, respectively.

In 2013, there were approximately 28,000 affected rental properties that met the risk reduction standard. With the law’s expansion to include all pre-1978 rental properties the number of properties treated and receiving risk reduction inspection certification more than doubled to over 57,603 properties in 2014.

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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.

West Baltimore Primary Care Access Collaboration

The West Baltimore Primary Care Access Collaboration (WBPCAC) is a group of sixteen organizations that aim to improve the overall health of the residents of west Baltimore. The mission of the Collaborative is to create a sustainable, replicable system of care, reduce costs and expand the primary care and community health workforce. In January 2013, the WBPCAC was awarded a five million dollar grant from the Maryland Community Health Resources Commission to reduce cardiovascular disease in west Baltimore in the four zip codes with the highest disease burden and most intense social needs of any other community in Maryland. To date, this is being accomplished by improving access to and the quality of healthcare by hiring 23 health care providers and providing training to many others. The WBPCAC has also deployed 11 Community Health Workers into these neighborhoods to partner with 172 community members to maximize their utilization of health and social services. To read more about this innovative program, see this brief summary [link]

Total Health at Kaiser Permanente

Total Health is a state of complete physical, mental, and social well-being. In 2013, Kaiser Permanente launched Total Health to help Kaiser Permanent members and workforce, their families, and communities achieve this vision of health. By focusing on chronic conditions driven by modifiable social and environmental determinants of health, Kaiser Permanente Total Health works to benefit communities through a variety of programs including: Thriving Schools initiative (300 schools participate) which aims to create a culture of wellness in schools including healthy meals; Every Body Walk! which raises awareness about the benefits of walking; and an incentive plan for the Kaiser Permanente workforce to improve health metrics. Partners include safety-net providers, fresh food providers, theatres, and grassroots organizations, in addition to schools and school-related organizations. Kaiser Permanente funds $2 billion that is needed annually for this population health work and supplemental funding is provided by partner organizations. To read more about this innovative program, see this brief summary [link].

Maryland Model for Hospital Payment

In 2014, Maryland and the Center for Medicare & Medicare Innovation (CMMI) negotiated a waiver that established a per capita expenditure rate for Medicare hospital services and a limit on the growth of inpatient and outpatient hospital costs for all payers to 3.58 percent. The waiver projects Medicare savings over five years to be $330 million. To implement the model, the state rate-setting commission will replace fee-for-service models with population-based payment models that reward providers for improving health outcomes, enhancing quality, and controlling costs. Although the new model has just been introduced, several early adoptees of the new payment models have observed significant reductions in preventable hospitalizations. With these new incentives, hospitals are expected to form more creative partnerships with public health agencies, community health organizations, and long-term care providers. To read more about this innovative program, see this brief summary [link].

Health Leads

Health Leads, operated by lay resource specialists and college student volunteers, is a collaborative comprised of partner hospitals, health systems, community health centers, and Federally Qualified Health Centers (FQHCs) working together to integrate basic resources such as access to food, heat, and other necessities into health care delivery. Operating via clinical settings since 1996, this initiative enables providers to prescribe solutions to patients helping them manage their disease and lives. The impact of Health Leads is two-fold. The program expands clinics’ capacity to secure nonmedical resources for patients— in 2013, 92 percent of patients identified that Health Leads helped them secure at least one resource they needed to be healthy. Additionally, Health Leads is producing a pipeline of new leaders—in 2013, nearly 70 percent of Health Leads graduates entered jobs or graduate study in the fields of health or poverty. Health Leads sustainability model utilizes earned revenue, national and local philanthropy, and in-kind contributions from volunteers and health care partners to fund its operation. To read more about this innovative program, see this brief summary [link].

An Action Plan for Reducing Absences Due to Asthma

The full version of this story, published by Healthy Schools Campaign, is available at https://healthyschoolscampaign.org/policy/an-action-plan-for-reducing-absences-due-to-asthma/. Below is just an introduction.

Asthma kept Stephanie Godbolt’s grandson John home from school time and time again. John’s school, Tench Tilghman Elementary, serves 425 students, more than 95 percent of whom are black and 95 percent of whom also qualify for free or reduced price lunch. The school sits in Baltimore’s Patterson Park neighborhood on the city’s southwest side, just a few blocks away from Johns Hopkins Hospital. John’s asthma got so bad, he was missing nearly a week of school each and every month for six months. And he was losing ground academically.

Improving the Health of Communities by Increasing Access to Affordable, Locally Grown Foods

BY MICHEL NISCHAN, CEO and Founder, Wholesome Wave

When my son was diagnosed with type 1 diabetes, I became painfully aware of the direct connection between food and health. As a chef, this realization caused me to transform the way I fed my family and customers. Fresh, nutrient-dense, locally grown foods became the foundation for the type of diet that would give my son and restaurant guests the best long-term health.

Quickly, though, I recognized that not every family can afford to purchase healthy foods. As a result, I founded Wholesome Wave in 2007.

Wholesome Wave is a 501(c)(3) nonprofit dedicated to making healthy, locally and regionally grown food affordable to everyone, regardless of income. We work collaboratively with underserved communities, nonprofits, farmers, farmers’ markets, healthcare providers, and government entities to form networks that improve health, increase fruit and vegetable consumption and generate revenue for small and mid-sized farms.

Double Value Coupon Program

In 2008, we launched the Double Value Coupon Program (DVCP), a network of more than 50 nutrition incentive programs operated at 305 farmers markets in 24 states and DC. The program provides customers with a monetary incentive when they spend their federal nutrition benefits at participating farmers markets. The incentive matches the amount spent and can be used to purchase healthy, fresh, locally grown fruits and vegetables.

Farmers and farmers’ markets benefit from this approach, and have been key allies as we work towards federal and local policy change.  In 2013, federal nutrition benefits and DVCP incentives accounted for $2.45 million in sales at farmers’ markets.

Communities also see an increase in economic activity.  The $2.45 million spent at local farmers’ markets creates a significant ripple effect. In addition to the dollars spent at markets, almost one-third of DVCP consumers said they planned to spend an average of nearly $30 at nearby businesses on market day, resulting in more than $1 million spent at local businesses. We also see that the demographics of market participants are more diverse – our approach breaks down social barriers and allows consumers who receive federal benefits to be seen as critical participants in local economies.

Equally as important, people are eating healthier. Our 2011 Diet and Behavior Shopping Study indicated 90 percent of DVCP consumers increased or greatly increased their consumption of fresh fruit and vegetables – a behavior change that continues well after market season ends.

Today, the program reaches more than 35,800 participants and their families and impacts more than 3,500 farmers. Combined with the new Food Insecurity Nutrition Incentives Program in the latest Farm Bill, this approach is now being scaled up with $100 million allocated for nutrition incentives over five years.

Fruit and Vegetable Prescription Program

We developed the Fruit and Vegetable Prescription Program (FVRx) to measure health outcomes linked to fruit and vegetable consumption. The four to six month program is designed to provide assistance to overweight and obese children who are affected by diet-related diseases such as type 2 diabetes. In 2013, the program impacted 1,288 children and adults in 5 states and DC. Nearly two-thirds of the participants are enrolled in SNAP and roughly a quarter receive WIC benefits.

The model works within the normal doctor-patient relationship.  During the visit, the doctor writes a prescription for produce that the patient’s family can redeem at participating farmers’ markets. The prescription includes at least one serving of produce per day for each patient and each family member – i.e., a family of four would receive $28 per week to spend on produce. In addition to the prescription, there are follow-up monthly meetings with the practitioner and a nutritionist to provide guidance and support for healthy eating, and to measure fruit and vegetable consumption.  Other medical follow-ups are performed, including tracking body mass index (BMI).

FVRx improves the health of participants. Forty-two percent of child participants saw a decrease in their BMI and 55 percent of participants increased their fruit and vegetable consumption by an average of two cups. In addition, families reported a significant increase in household food security.

Each dollar invested in the program provides healthier foods for participants, boosts income for small and mid-sized farms and supports the overall health of the community. As with the DVCP, there are benefits for producers and communities.  In 2012 alone, FVRx brought in $120,000 in additional revenue for the 26 participating markets.

In less than seven years, Wholesome Wave has extended its reach to 25 states and DC and is working with more than 60 community-based organizations, community healthcare centers in six states, two hospital systems, and many others. Our work proves that increasing access to affordable healthy food is a powerful social equalizer, health improver, economic driver and community builder.

Wholesome Wave is working to change the world we eat in. As the number of on-the-ground partners increases, we get closer to a more equitable food system for everyone.  This means healthier citizens and communities, and a more vibrant economy nationwide.