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doi:10.1378/chest.07-1912
(Chest. 2007; 132:840S-852)
© 2007 American College of Chest Physicians
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A Review of Potential State and Local Policies To Reduce Asthma Disparities*

Sarah K. Lyon-Callo, MA, MS; Leslie P. Boss, MPH, PhD{dagger} and Marielena Lara, MD, MPH

* From the Bureau of Epidemiology (Ms. Lyon-Callo), Michigan Department of Community Health, Lansing, MI; and the RAND Corporation (Dr. Lara), Santa Monica, CA. {dagger} Retired.

Correspondence to: Sarah Lyon-Callo, MA, MS, Section Manager, Chronic Disease Epidemiology Section, Epidemiology Services Division, Bureau of Epidemiology, Michigan Department of Community Health, 201 Capitol View, Fourth Floor, Lansing, MI 48909; e-mail: lyoncallos{at}michigan.gov


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
Although policies promoting asthma-friendly communities should reduce asthma disparities, not much is known about the status of policy implementation or effectiveness. We review the efforts of state and local agencies to identify and target asthma disparities for reduction, as evidenced by written laws and policy documents and use of funding. Policies targeting health care, homes, schools, and workplaces hold promise for creating asthma-friendly communities; however, the scope and reach of these activities must be increased to have statewide or national impact. In addition, there is a general lack of systematic review of evidence about the institutionalization of successful demonstration programs into policy.

Key Words: asthma • disparities • health policy • inequality • minority groups • public policy • socioeconomic factors


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
The burden of asthma in the United States varies by age, race and ethnicity, gender, income, geographic residence, primary language, education, and literacy.1234 Even with recent reductions in rates of severe asthma events, disparities continue.1234 State and local municipalities can act to reduce asthma disparities through their multiple roles as regulators in health care, education, and environmental arenas; promoters of public health awareness and intervention activities; sources of funding and quality assurance for Medicaid and safety net systems; and purchasers of health care for governmental employees. Nongovernmental organizations, such as professional organizations and foundations, play a role in reducing health disparities through advocacy, policy development, funding, and implementation of programs.

Policies to promote asthma-friendly communities, that is, communities in which people with asthma receive a quick and accurate diagnosis, receive appropriate treatment, and are safe from physical and social environmental risks that exacerbate asthma,5 have been proposed at the national level. Although integration of policy activities at the national, state, and local levels is important to reach the goal of asthma-friendly communities for all, the purpose of this review is to describe the specific role that state and local policies can have in reducing asthma disparities.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Conclusion
 References
 
In this review, asthma disparities are defined as differences in outcomes and management by race and ethnicity, gender, income, geography, language, literacy, and/or insurance status. Policy was defined broadly as "... purposeful action by an organization or institution to address an identified problem or issue through executive, legislative or administrative means."6

We conducted a literature review of articles on asthma policies using PubMed, with an emphasis on disparities. The bibliographies of relevant papers were also examined to identify other references. Additional online searches of state and local associations addressing health policies were conducted using World Wide Web search engines and following links from identified Web sites. The facilitator and members of the State and Local Policy Workgroup of the National Workshop to Reduce Asthma Disparities provided review and comment on the results of the literature and Web search and a set of preliminary conclusions.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Conclusion
 References
 
National, state, and local governments have increased attention to health disparities in recent years.578910111213141516171819202122 A number of federal agencies and national foundations are funding activities that have the potential to reduce asthma disparities at state, county, city, and health-care provider levels.10111213141516171819202122232425 Three reports deserve specific mention: (1) "Improving Childhood Asthma Outcomes in the United States: a Blueprint for Policy Action"5 provides a framework for developing asthma-friendly communities and 11 specific recommendations for improving health-care delivery and financing and for strengthening the public health infrastructure; (2) "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care"18 contains recommendations to improve legal, regulatory and policy arenas and health systems; provide patient education and empowerment; provide cross-cultural education in the health professions; improve data collection and monitoring; and address research needs; and (3) "State Policy Agenda To Eliminate Racial and Ethnic Health Disparities"9 provides state policy makers with a menu of interventions to address minority health disparities, including interventions in addressing asthma.

A consolidation of the recommendations in these policy documents5918 provides a model policy framework (Table 1Go ) to explore the potential for state and local policies to reduce asthma disparities. The policy framework encompasses the following: (1) health-care access and financing; (2) quality of health-care delivery; (3) health-care workforce diversity and cultural competency; (4) data collection and surveillance; (5) public health infrastructure; and (6) the development of asthma-friendly environments in homes, schools, and workplaces. For five of these areas, we provide examples of existing state and local policies or programs that may reduce asthma disparities (Table 2Go ). The policy framework recommendations regarding the diversity and cultural competencies of health-care professionals are covered in depth by Cabana (see page 810S) in this volume and will not be discussed here. The majority of activities and policy initiatives described below are in early stages of implementation and/or conducted in isolated areas or sites across the nation.


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  		Table 1. Summary of Policy Recommendations for Reducing Disparities and Developing Asthma Friendly Communities

 

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  		Table 1A. Continued

 

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  		Table 2. Selected Examples of State and Local Policies and Activities That Could Reduce Asthma Disparities

 

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  		Table 2A. Continued

 
Access to Health Care
The policy framework recommends extending continuous health-care coverage to all uninsured children and addressing coverage for adults and immigrant populations. Shields in this volume (see page 818S) provides an excellent review of private and public health-care trends, including the benefits of the expansion in Medicaid, the State Children’s Health Insurance Program, and federal qualified community health centers, and the potential of pay-for-performance, disease management, and information technology efforts to reduce disparities. We will not duplicate her work here; rather focus on state or local initiatives that particularly deal with increasing the likelihood that people with asthma have health coverage. Some states, counties, and cities are promoting and implementing policies to increase the number of people with chronic diseases, including asthma, who have health care coverage and access.16172125 Seven states have included asthma in their definitions of medically fragile or disability,7 increasing the likelihood that children with severe asthma can obtain health-care coverage or services. Some states have passed specific laws or regulations (Table 2)Go trying to reduce barriers (such as copayments) to obtaining asthma services or medications for children, the elderly, and economically disadvantaged populations.7

Other states and local communities fund programs to bring quality asthma care directly to children in areas of highest need, focusing on school-based health centers192526 or mobile clinics such as the "Breathmobiles"23 (Table 2)Go, to provide asthma diagnostic, clinical, and education services to students on a routine basis. For example, a New Mexico Medicaid program is funding pediatric pulmonary clinics in outlying areas experiencing highest asthma rates.7 Hawaii is conducting a childhood asthma project using rural community health centers11 (Table 2)Go. Texas law mandates implementation of Medicaid disease management programs for asthma in counties with a high pediatric asthma incidence and rates of emergency department visits.7 All of these policies and programs are meant to increase access to quality asthma care for populations of greatest need.

Quality of Asthma Care Delivery
Promoting the consistency and equity of health care using evidence-based guidelines, including the use of performance measures for asthma care and disparities, is a theme common to all three policy documents. State and local policies can drive health systems changes by setting standards of care and performance measurement; funding improvements in processes of care; and/or requiring various levels of disease management for people with asthma receiving state-funded health care.

A number of initiatives at the national,19202124 state and county7161718252728 levels promote reimbursement systems that provide adequate funding for quality asthma care, as part of an overall effort to improve primary care for chronic diseases. For example, California27 is using an 1115 Medicaid Waiver to restructure the health-care delivery system in Los Angeles County to rely more on primary preventive care than acute care. This waiver includes resources to restructure levels of reimbursement and performance measurement, provide health services to indigent populations, and provide reimbursements to clinics that are participating in the demonstration.

Some state and local agencies are forming public/private partnerships to determine quality and performance standards for asthma care (Table 2)Go.11252728 For example, Oregon is developing and implementing performance measures to promote consistency and equity of care in state health plans, with an emphasis on high-risk asthma patients (Table 2)Go. Certification standards for asthma management and education standards can also be developed, similar to those in some states for diabetes care and education.29

Numerous asthma interventions11252830 involving both clinical and community components are targeted and tailored for low-income and disadvantaged populations. "Yes We Can" of San Francisco (Table 2)Go targets low-income children through changes in primary care clinics, provider education, clinical care coordination for high-risk children, and high-risk case finding with aggressive follow-up. A number of state minority health programs7 target asthma funding to programs already serving low-income and minority children (Table 2)Go.

Data Collection, Surveillance, and Assessment
Recommendations from national organizations192231 emphasize the need to collect and report data on health-care access and utilization by race, ethnicity, socioeconomic status, and primary language, as well as to monitor environmental exposures and their impact on asthma. These data are essential to raise awareness of disparities, to develop interventions and target health services and programs, and to evaluate program effectiveness. The policy framework recommends state governments alter purchasing contracts and certification processes to require plans and health-care providers to collect needed demographic data.

The most sophisticated surveillance systems measure asthma prevalence, mortality, hospitalizations, and emergency department visits; survey asthma management, trigger exposure, and quality of life; and review clinical and pharmacy utilization for Medicaid and health plan members.11 Most states are unable to collect or obtain data in the geographic and demographic detail needed to adequately monitor asthma disparities.32 In addition, the incompatibility of the collection of race and ethnicity in the 2000 Census and in health data systems has complicated the calculation of health statistics by race and ethnicity and limited the value of these health statistics in understanding disparities at the local level over time.33 A few states have disparity reporting efforts underway that can also raise awareness of the need for improved data collection for identifying and monitoring asthma disparities.16

Many health service delivery systems do not collect racial and ethnic data34 due to concerns over antidiscrimination obligations, perceived legal barriers, and confidentiality. State regulations on data collection by health management organizations vary from requiring to prohibiting collection of race/ethnicity or primary language.734 The variation in data collection among states may be a barrier to disparity reduction approaches driven by performance measurements and quality improvement techniques. As described above, some states and collaboratives are developing performance measurement systems to help identify and target disparities in asthma care (Table 2)Go.

Public Health Infrastructure
The policy framework recommends improvements to the public health infrastructure, including public health grants fostering asthma-friendly communities, home environments, and schools. The policy framework also recommends increasing cultural and linguistic competencies of public health institutions and work force, and developing state minority health infrastructure.

Since the late 1990s, federal, state, and local public health agencies have been developing plans for addressing asthma and funding public health activities and partnerships,101113 many of which directly address reduction of asthma disparities. A number of state legislatures7 have directed health departments to develop asthma programs that target asthma activities to populations with highest needs. All published State Asthma Plans aim to reduce asthma disparities by targeting activities to high risk or vulnerable populations.11 Some other states have institutionalized asthma outreach into existing disparity reduction programs.716 Nebraska laws require the health department to establish and fund Offices of Minority Health in each congressional district that will target asthma (Table 2)Go. New Jersey’s Office on Minority and Multicultural Health is to develop innovative projects to reduce dramatic differences in asthma rates between white and minority populations (Table 2)Go.

Federal, state, and local asthma funding is also often targeted at populations experiencing disparities. Federal agencies and national foundations have funded efforts to develop asthma-friendly communities in urban areas that should determine if the community coalition approach can reduce disparities.1115353637 Some state and local governments, health systems, and foundations are targeting funding for local asthma coalitions to areas of highest asthma burden.718253637 The challenge is to maintain the programs once the grant or foundation funding is gone.

Reducing Asthma Disparities in Homes, Schools, and Workplaces
Barriers to self-management, including environmental exposures that can exacerbate asthma, differ by race, ethnicity, and socioeconomic status. Changes to and enforcement of state and local housing codes and landlord/tenant laws may help to address asthma disparities.16363839404142 Some states and cities are developing collaboratives between public health, housing, and construction departments to address housing codes content and enforcement.40 In-home assessment and remediation activities ("Healthy Homes" initiatives) are also underway.16253640424344 These programs tend to be grant or foundation funded and institutionalizing functions into existing public health activities will probably be a challenge.

Policies addressing tobacco use and secondhand smoke exposure reduce asthma exacerbations in people of all ages.44454647 The Institute of Medicine38 has identified the need to reduce exposure to secondhand smoke, particularly in "children at greatest risk for adverse asthma outcomes." The number of policies reducing exposure to secondhand smoke has increased at the state and local levels, although preemption efforts are also underway.45 Thirty-nine states have policies addressing tobacco use in school buildings or on school property, including four states whose policies explicitly prohibit use of tobacco by students, staff members, and school visitors.8 States have also been implementing awareness campaigns, tailoring and targeting asthma and secondhand smoke messages to specific populations. For example, some states and cities are working with the Environmental Protection Agency smoke-free homes campaigns to raise awareness of the relationship between asthma and secondhand smoke, including tailoring these campaigns to particular communities.113644

Federal agencies and national associations811424447 have developed guidance documents outlining policies and procedures for asthma-friendly schools. A number of state legislatures and boards of education have passed a variety of asthma policies.8 As of December 2004, 33 states have policies that allow students to carry and self-administer medications in schools. Twenty-eight states require that individual education or health plans incorporate accommodations and medical instructions for students with chronic health conditions. Eleven states mention asthma awareness or education in their policy related to school health curricula. No state has a written policy requiring professional development for school staff on asthma awareness, management, or emergency response. Twenty-three states have policies addressing indoor air quality and 24 states have policies on pesticide use on school grounds.8 The Environmental Protection Agency is promoting changes to school policies on bus driving/loading procedures to reduce exposure to diesel exhaust44 (Table 2)Go.

Reducing the proximity of housing, schools, and day-care facilities to highly trafficked roadways and point sources of ambient air pollutants known to exacerbate asthma364248 is another important policy area. Antisprawl and outdoor air quality initiatives could help to decrease exposure to allergens/irritants. For example, California fuel economy standards cite the relationship of asthma to outdoor air pollutants.723 Additional research is needed on the impact of these policies on reducing asthma rates in communities most affected by pollution.36

Workplace exposures can also cause asthma or exacerbate existing asthma.49 The National Institutes for Occupational Safety and Health is funding four states to conduct case identification, exposure reduction, and education activities with workers and employers that can reduce asthma disparities by preventing occupational asthma.50 For example, the Michigan system reports on the incidence of occupational asthma by sex, race, smoking status, and county of employment.50 These data are used to initiate investigations of workplaces, targeting industries and occupational groups with the highest rates of disease and exposures. In addition to federal funding, state law50 requiring reporting of occupational disease makes this system possible.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Conclusion
 References
 
The purpose of this review was to identify policies that have been shown to or have the potential to reduce asthma disparities, as well as discuss a number of activities or interventions that could lead to policies in the future. There are promising examples. Some states and local communities are attempting to target limited health dollars and public health resources to areas with greatest need. School policies may improve asthma management, educate students about asthma, and improve the indoor environment. Similarly, ordinances ensuring smoke-free work places, schools, and public places hold great promise for reducing asthma triggers. Although several activities across public and private sectors have the potential to reduce asthma disparities, we found a general lack of peer-reviewed, published evidence-based programs or policies. The implementation of these policies remains sketchy at best, related perhaps, to lack of education and political will resulting in inadequate funding of recommendations.

There are also obvious gaps in policy activity. For example, comprehensive data systems, including information on race/ethnicity, socioeconomic status, literacy, primary language and geography, are needed to monitor trends in asthma management, outcomes and trigger exposure. A number of state and local collaboratives are developing systems that routinely measure asthma management and react accordingly. However, policies need to support the inclusion of detailed sociodemographic information in the systems and provide for the routine examination of data to identify disparities in asthma management.

Policies on educating and training school staff about asthma are also lacking, as is evidence of policies improving asthma management and environments in the child-care setting. Similarly, although housing code enforcement efforts may be institutionalized into existing public health activities, there is currently no source of funding for in-home remediation of asthma triggers. The case needs to be developed for making asthma education, management devices, and materials for reducing in-home triggers (eg, mite-impermeable bed covers) a reimbursable part of case management services. The Community Health Worker model for environmental control of asthma triggers and improvement of coordination of asthma services also hold much promise.36 Evaluation of the feasibility and impact of these activities should continue. In addition, much more work is needed on the impact of planning policy on reducing proximity of homes, schools, and day cares to high traffic roadways.

Asthma policies are relatively new, and variation in policies across states and localities is a cross cutting theme of this review. While the definition of asthma-friendly community should be consistent, some variation in policy is to be expected, as different areas will have different policy needs. This variation provides many "natural experiments" into which policies may be effective in particular situations. However, policies promoting the development of asthma-friendly communities hold promise for reducing disparities only if policies and interventions appropriately address all subpopulations. The results of these natural experiments always should be evaluated. Following continued evaluation, success or failure of implementation strategies of existing policies need to be shared widely with other state and local communities and organizations.

Another theme in this review was the important role that federal resources and guidance play in development and evaluation of asthma activities at the state and local levels. Federal dollars and flexibility in funding guidelines allow states and local areas the opportunity to innovate. For example, reducing asthma disparities in the health-care system requires funding for system level changes, including setting quality standards, measuring performance, and altering reimbursement to provide for adequate asthma management. To date, state and local agencies rely heavily on federal resources from agencies such as the Centers for Medicaid and Medicare Services, Health Resources and Services Administration, and Agency for Healthcare Research and Quality to implement system changes. Expanding and maintaining health system changes will require investment. In the absence of additional funding, state and local governments and health-care providers will only be able to make this investment if long-term cost neutrality or savings are documented. Areas with fewest resources will have the most difficult time making such an investment, thereby potentially increasing disparities in access and quality of care.

The lack of information on the health impact of asthma policy was a critical limitation of this review. Many of the activities described regard newly implemented policies or statements of intention to act, rather than describing published evaluations of implemented policies. Only a sampling of policies and activities are presented here, not an exhaustive compendium of state and local activities. Even for those activities or policies with demonstrable efficacy, there is limited information on their effectiveness over time. Furthermore, the existing information on local level activities is not routinely summarized for use by public health. Asthma is a relatively recent addition to state and local public health activities, and determining what activities and policies are most effective will take time. Evaluation of the impact of these policy activities would be beneficial before other states and localities institute asthma policies. All these findings point to the need for a routine, systematic review of the impact of community and policy interventions, combined with a method for disseminating those findings to communities across the country. This holds true for asthma, as well as other chronic illnesses and primary prevention strategies.


   Conclusion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
References
 
National, state, and local agencies and foundations are making efforts to explicitly identify and reduce asthma disparities. State and local agencies are producing reports describing disparities, and laws and policy documents indicate intention to reduce asthma disparities. Policies targeting the distribution of health care resources and addressing asthma management in home, school, and work place settings hold promise for creating asthma-friendly communities. However, much of this policy innovation has been financed or supported by national initiatives and organizations, and the scope and reach of these activities have been necessarily limited. To achieve a broad and sustainable reduction of asthma disparities, these local demonstration projects must be routinely assessed and, when shown affective and affordable, shared widely and quickly with other state and local agencies. Evidence is needed to enable states to justify investment of limited state funds in these practices. Furthermore, policies must be in place to ensure data systems are adequate to identify and monitor changes in asthma disparities over time.


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  		Table 2B. Continued

 

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  		Table 2C. Continued

 

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  		Table 2D. Continued

 

   Acknowledgements
 
The authors thank the State and Local Policy Work Group of the National Workshop To Reduce Asthma Disparities for their contributions.


   Footnotes
 
This work was performed at the Michigan Department of Community Health and the RAND Corporation.

The authors have no conflicts of interest to disclose.

Received for publication December 20, 2006. Accepted for publication August 2, 2007.


   References
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 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 

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