State Category: Massachusetts

Massachusetts’ Efforts to Prevent and Respond to Childhood Lead Exposure

Background

The Massachusetts lead law, enacted in 1971, is one of the oldest in the country and contains some provisions not found in many other states. The law requires that any property built before 1978 and occupied by a child under age six be “deleaded.” The statute applies to both rental and owner-occupied dwellings and embodies the principle of primary prevention. This means that the requirement to delead is triggered by the occupancy of a child not by whether a child is experiencing an elevated blood lead level. Massachusetts also has laws making it illegal for property owners to discriminate against families with children when renting or selling.

The Massachusetts lead law, which has been amended multiple times since originally enacted, requires owners to hire a lead inspector to identify all surfaces with lead-based paint and develop a plan to address lead hazards. In some cases, the owner or agent can be trained to address certain conditions, while in others, a contractor with a Massachusetts deleaders’ license must be hired to conduct the work. Owners can opt to receive a Letter of Interim Control, which means that they will address “urgent lead hazards” immediately but defer action on intact surfaces. They must then fully cover or remove all lead hazards within two years of the issuance of the Letter of Interim Control. If an inspection does not identify lead hazards, or if owners fully address lead hazards, the inspector issues a Letter of Full Compliance. Although a Letter of Full Compliance does not expire, it does not certify a dwelling is lead-free, and therefore it is the owner’s responsibility to check the dwelling routinely for new hazards.

Strict Disclosure Requirements

Massachusetts law provides strict lead disclosure requirements for prospective renters and buyers of residential units. The law is in compliance with the federal lead disclosure law and includes the notification materials mandated by the Department of Housing and Urban Development and Environmental Protection Agency. In addition, landlords must provide tenants with a Massachusetts Tenant Lead Law Notification and Certification Form, a copy of the most recent lead inspection report if the property has been inspected for lead, and a copy of any Letter of Compliance or Letter of Interim Control.ta

Before signing a purchase and sale agreement, a lease with an option to purchase, or a memorandum of agreement used in foreclosure sales, residential property sellers and real estate agents – must disclose any lead-related information on the property to the prospective purchaser. This includes a copy of any lead inspection report, risk assessment report, Letter of Compliance, or Letter of Interim Control. Real estate agents must also tell prospective purchasers that, under the Lead Law, a new owner of a home built before 1978 (in which a child under six will reside) must have it deleaded or under interim control within 90 days of taking title.

Although the Massachusetts law includes many of the provisions found in federal law, Massachusetts gives the state enforcement powers. If the landlord fails to comply with the disclosure requirements, he or she can be held liable for all damages caused by the failure to provide this information, fined up to $1,000, and may be liable for engaging in an unfair and deceptive act under the Massachusetts Consumer Protection Act. Sellers and real estate agents who do not meet these requirements can face a civil penalty of up to $1,000 under state law in addition to a civil penalty of up to $10,000 and possible criminal sanctions under federal law, as well as liability for resulting damages. If a real estate agent fails to tell a tenant or perspective buyer about known lead hazards at a property, he or she may be liable for engaging in an unfair or deceptive act in violation of the Massachusetts Consumer Protection Act.

Strict Legal Liability for Property Owners

If an owner of a pre-1978 home fails to delead the property, and a child younger than six living in the home is lead-poisoned, the property owner is strictly liable for all damages. Strict liability means that owners are liable even if they did not know lead paint or a child under six was in the home. The strict liability provision, which dates back to the original law passed in 1971, helped educate property owners about their responsibility in correcting lead hazards.

In 1993, the law was amended so that an owner is not strictly liable for lead poisoning if a Letter of Compliance or Letter of Interim Control is in effect. The 1993 amendments also require insurance carriers who provide liability coverage in the state to offer owners coverage for negligence claims (short of gross or willful negligence) that might be brought against them by their tenants.

Financing Prevention Efforts

Beginning in 1987, Massachusetts has provided a “deleading” income tax credit to help homeowners pay for the cost of abating lead hazards, including window replacement. Since 1993, an owner of a residential property can claim a tax credit up to $1,500 for addressing lead hazards, if they have a Letter of Compliance, or up to $500 if they have a Letter of Interim Control. The tax credit cannot exceed the actual amount spent by the owner. If the tax filer owes less in income taxes than the amount of the credit, the unused portion of the credit can be carried over and used within the next seven years.

The state also administers loan programs for owner occupants and rental property owners to support compliance with the lead law. Some, such as Get the Lead Out and the Home Improvement Loan, are funded by the state, while others use federal grants and loans to support lead hazard control.

In order to provide additional funds to pay for training, licensing of inspectors, and public education purposes, Massachusetts imposes surcharges of $25 to $100 on the annual fees of a variety of professional licenses, including real estate brokers, property and casualty insurance agents, mortgage brokers and lenders, small loan agencies, and individuals licensed to perform lead inspections. The collected revenue, roughly $2.5 million annually, is deposited into a retained revenue account, known as the Lead Paint Education and Training Trust Account, for use by the Department of Public Health.

Results
Massachusetts’s comprehensive approach over a number of years has successfully reduced the number of young children with elevated lead blood levels.  Of the more than 175,000 children tested in 2016, just 686 under age six had blood levels of 10 µg/dL or greater, compared with 3,095 of about 194,000 children tested in 2001, the earliest date for which data is available online.

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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.

HelpSteps

HelpSteps is an online assessment and referral system for families’ and individuals’ social determinants of health. It began as a research project in 2003 and became a fully implemented referral system in 2007. The online system assesses needs in 13 broad social domains and provides access to resources related to over 100 social problems that affect lower socioeconomic families, including services related to food insecurity, housing, and income resources. The system is used by a variety of social services in the Boston area, including the Boston Public Health Commission, The Mayor’s Health Line, and medical and free clinics throughout the area. HelpSteps findings include: 82 percent of families in urban clinics experience at least one type of social problem in a given year; families are interested in assessment referrals; 40 percent of individuals who selected referrals followed up with one of their selections; 52 percent said their problem had either completely or mostly resolved; and 80 percent stated they would like to use the online tool as part of an annual assessment. HelpSteps receives funding from the Boston Children’s Hospital, the Boston Public Health Commission, and small grants. 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].

Boston Children’s Hospital Community Asthma Initiative

The Community Asthma Initiative (CAI), an initiative of Boston Children’s Hospital, began addressing health disparities in Boston neighborhoods impacted by asthma in 2005. CAI provides an enhanced model of care which includes asthma education and home visits for families with children ages 2–18 living in the Greater Boston area who were previously treated in the Emergency Department (ED) or hospitalized as a result of asthma. CAI works with partners and coalitions to address asthma health disparities by implementing changes in policies at the local and state levels. As of June 2014, case management had been provided to 1,329 patients with significant outcomes including: a 57 percent reduction in the number of children with ED visits; a 79 percent reduction in hospitalizations; a 43 percent reduction in missed school days; and 43 percent reduction in missed work days for parents. CAI is supported in part by grants, several foundations, philanthropy, Centers for Disease Control REACH US Program, American Academy of Pediatrics, the Office of Community Health at Boston’s Children’s Hospital and others. To read more about this innovative program, see this brief summary [link].

Communities That Care Coalition

The Communities That Care Coalition began in 2000 in Western Massachusetts to reduce youth substance abuse and improve youth health. The program brought together and coordinated the efforts of various local stakeholders including schools, youth and parent groups, law enforcement, health care providers, and the local hospitals. By implementing its Community Action Plan—which includes an annual Teen Health Survey, anti-substance curricula in local schools, social marketing, and forming strategic partnerships within the community—the Coalition has been successful in identifying several underlying risk factors of youth substance use in the area and priorities for improvement. During the 12 years of its work, the Coalition has measured substantial improvements in youth substance abuse, as well as a reduction in the underlying factors causing it. The Coalition is supported by state and federal grants. To read more about this innovative program, see this brief summary [link].

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.