This state has by far the most comprehensive legislative, statutory and programmatic approach to asthma. The complexity of California's statutory response to asthma is a result of the state's size (The largest population and fourth largest in land area in the United States), its use of local public health agencies to administer programs, and the extent of legislative involvement in developing public policy. The Legislature, the most comprehensive of any state (even with a 40 percent budget cut to the Legislature's appropriation mandated by a citizen's initiative), is in session year-round with several personal staff. The Assembly members represent districts of close to 400,000 people, and Senate districts (larger than congressional ones) represent 800,000 people.
California also has unlimited bill introduction, which allows legislators to introduce any number of bills. Its budget surpasses those of all other states, even with the huge deficit the state is facing this year. These factors give the state the ability to develop unique, comprehensive and innovative approaches to addressing asthma.
Californians are particularly concerned about asthma in their state since nearly 12 percent of Californians report that they have been diagnosed with asthma at some point in their lives. This makes California lifetime asthma rates higher than the 9.7 percent national average.1
The costs of asthma in the state have been estimated at approximately $720 million in direct medical expenditures and $544 million in lost school and work days at a cost to the state of more than $1.2 billion.
According to workers at the state agency of Health and Human Services, laws have not significantly affected current asthma activity in California. The last bill that was enacted to create an asthma program, AB 2877 in July 2000, was unfunded. Still, California is attempting to create a comprehensive program using available resources. Most of the work is done with support from the CDC, the California Lung Association, the California Children and Families Commission, and the California Endowment, the state's largest health care foundation.
Asthma is addressed by a host of different programs:
Children's Medical Disability
The California Children and Families Act of 1998
Children's Medical Services
The Chronic Diseases Division
The Environmental Health Division
looks at occupational asthma in the workplace with assistance from the National Institute of Occupational Safety and Health. It also investigates schools and other public places to assess and control exposures to potential asthma triggers.program conducts community interventions, education and some surveillance. supplements medication costs in clinics, medical monitoring and asthma education.is designed to provide all children prenatal to age 5 with comprehensive, integrated childhood development services. It also provides asthma services. Also known as Proposition 10, the act allots 10 cents from each pack of cigarettes sold to a fund that the California Children and Families Commission distributes to child health programs. The California Childhood Asthma Initiative receives money from the commission, which is providing $12.5 million over four years (2000-2004). The Asthma Initiative provides grants to communities for a variety of services such as asthma interventions, provider education, asthma treatment services and epidemiological studies. Some of the projects funded include a survey of child care centers, assistance for children who do not qualify for Medi-Cal but cannot afford asthma treatment, and community education programs that focus on improving asthma management. provides supplemental insurance paid to private insurance companies. This plan was adopted in lieu of extending Medi-Cal. provides some medical care for poor children with asthma. California's version of Medicaid, is funded jointly by California and the federal government. Approximately $400 million is spent to treat clinical aspects of asthma. The Medicaid program pays one-third of this expense.
Currently, California tracks asthma mortality and asthma hospitalization; emergency room visits will be added in 2003. Some clinical visits using Medi-Cal data are monitored as well, although this has been perceived as ineffective due to the inconsistency of the Medi-Cal data. The Health Department currently is attempting to work with Kaiser Permanente to obtain all clinical asthma encounter data. Data are also collected through the use of surveys modeled after CDC's Behavioral Risk Factor Surveillance System.
California conducts a school survey of asthma rates in the student population, including undiagnosed asthma for fifth, seventh, ninth and 11th graders. Information also is gathered from worker's compensation doctors, who provide first reports of the illness in the workplace. The CDC assists in tracking occupational asthma.
Bills and Statutes
CA SB 1932
An individual may designate on the tax return that a contribution in excess of the tax liability, if any, be made to the California Lung Disease and Asthma Research Fund, which is established by Section 18832. Passed.
States that the balance of the $2,114,000 for the Childhood Asthma Initiative is reappropriated for the program in fiscal year 2001-02, subject to the limitations provided for in the appropriation.
Cal. Health & Safety Code § 104316
Cal. Health & Safety Code § 104317
Cal. Health & Safety Code § 104318
Cal. Health & Safety Code § 104317-21
Cal. Health & Safety Code § 104320
Cal. Health & Safety Code § 104319
Cal. Health & Safety Code § 104321
Cal. Rev. & Tax Code § 17052.18
The Connecticut General Assembly, traditionally has been controlled by Democrats but tempered by a strong Republican minority. Except for a two-year session in the mid-1990s, Republicans have not had the majority in either house.
The governor is exceptionally strong in the state, however, and in recent years has been a Republican. The governor drafts and submits the budget to the legislature for ratification. Because the governor usually works with the lieutenant governor and speaker on the budget, the legislature generally accepts the budget without comment. The budget reflects the pro-business nature of the state, permitting public health programs as long as they do not conflict with health insurance concerns.
The Department of Public Health (DPH) has certain mandates regarding asthma, due to legislation and to the commissioner of health, whose direction comes from the governor's office. Its most significant efforts are tracking and assessing the extent of asthma in the state and developing a statewide strategy in response. Because asthma is a chronic disease, it is listed under the state's chronic disease registry.
It has been estimated that medical costs related to asthma in the state are $75 million and costs due to lost work and school days are $58 million, making the total cost $133 million annually.
The legislature authorized this assessment and surveillance through Conn. Gen. Stat. § 19a-41. This law requires the DPH to survey asthma rates and treatments through local health departments in each of the state's 169 towns. Each town acts independently of the others, making compilation of data difficult. The law also directs each board of education to perform a health assessment on every sixth and 12th grader, including information about asthma.
Currently, the state funds half the asthma program; funds from CDC cover the other half. These funds, which support community and local asthma efforts, are being cut back due to state budget restrictions. (DPH is canceling several grants to local health departments to perform asthma surveillance and education.)
DPH uses the data from this surveillance effort to devise a statewide strategy. The strategy was developed during the state asthma summit, held in spring 2001. This summit outlined the problem of asthma within the state and drafted four areas of response: clinical management, professional education, public education, and environmental. Clinical management addressed the need to work with health providers as public health practitioners. Professional education is an effort to enlighten health professionals about the issue. Public education offers outreach to the public, and environmental focuses on the environmental factors that trigger asthma.
This summit led to the development of a statewide strategy. A task force of state and local officials and community activists was convened to discuss and devise a strategy, which must be presented to the commissioner. The task force defines priorities for DPH to undertake, including legislative and policy needs, and provides the base of concerns for the statewide strategy. After the strategy is approved, DPH will implement the program beginning in 2003.
Bills and Statutes
More than 20 bills have been introduced in the legislature during the past three sessions. These bills address various aspects of asthma policy, but the main laws enacted deal with tracking and monitoring asthma cases. Conn. Gen. Stat. § 9a-41 requires DPH to assess the extent of asthma cases in the state, monitoring treatments and identifying cases through local health clinics and through the school system. Clinics report asthma as part of the chronic disease registry, and local boards of education must require screening of children for asthma before they enter the sixth or 12th grade.
In addition, the legislature adopted a pilot program for the early identification and treatment of pediatric asthma (Conn. Gen. Stat. § 19a-62a). This statute directs the commissioner of public health to study, identify, screen and refer children with asthma for treatment in two cities. Upon completion of this study, the commissioner must report to the General Assembly the findings and recommendations to address pediatric asthma. The commissioner also must monitor asthma rates from surveys by schools and health care providers, determining which populations suffer from the disease. The commissioner also must develop a statewide plan for addressing asthma.
Asthma medication is not taxed, as specified in the tax code (Conn. Gen. Stat. § 12-412). The air pollution control compact determines that air pollution adversely affects asthma (Conn. Gen. Stat. § 22a-166).
This state has a strong governor/weak legislature system. The legislature meets three months (40 calendar days) out of the year, does not draft a budget (only approves), and generally cannot initiate any large-scale programs. It takes its appropriations role very seriously, however, by amending and revising the governor's budget to suit its needs. The legislature also has many interim committees to address policies it cannot address during its 40-day session.
The lieutenant governor and speaker control the legislature, forcing the governor to work closely with these two officers to ensure the budget remains intact.
Republicans have made steady gains in Georgia, particularly in suburban and rural areas, but have never mustered enough votes to control either the house or senate.
The state relies heavily on the CDC and Emory University to supply its public health agenda, using these resources to support policy and line items in the budget. Asthma-related illness in the state costs $168 million in medical expenses and $127 million in lost school and work days.
The state's asthma program, within the Department of Human Services (DHS), is entirely funded by the CDC through a five-year grant. In its initial stages, the DHS program is attempting to partner with other programs and projects to form a cohesive state work force. This effort seeks to work with local and county governments to develop a statewide response to the rising asthma rates. DHS does not deal directly with the legislature; rather, it must go through the governor's office to request policy changes and appropriations.
Bills and Statutes
The legislature has introduced legislation on asthma, and has enacted several laws related to it. Senate Bill 472 (passed in 2002) permits the self-administration of asthma medication by students and exempts to schools from liability resulting from this use. House Bill 1242 (died 2002) sought to amend the Georgia Safe Schools Act to create a school integrated pest management advisory board to address pesticide exposures in schools, since pesticides can trigger asthma attacks.
In the 1999-2000 budget cycle, the legislature appropriated $19,000 to establish an asthma coordination program that included public education and prevention, best asthma management practices and technical training (Ga. Code § 42-3252). Ga. Code § 33-24-28.2 requires general insurance providers to include asthma as a medical emergency. Ga. Code § 49-5-273 prohibits copayments for children under age 6 for asthma-related conditions; Ga. Code § 33-24-59.8 prohibits medical insurers from denying or limiting coverage for prescription asthma inhalants based on refill frequency. Ga. Code § 16-13-29.1 excludes certain anti-asthma medication from schedules of controlled substances. Ga. Code § 43-30-1 requires optometrists to refer patients with asthma to a licensed person for examination before certain types of optical therapy can begin.
Illinois' General Assembly is comprehensive, remaining in session year-round and commanding state policy. It initiates, reviews and enacts legislation; advises and approves the governor's appointments to state offices and commissions; and, most importantly, adopts the state's budget.
The Illinois governor appoints more officials than do governors in other states. Close to 9,000 people are directly appointed to state agencies, boards and commissions by the governor, making legislative oversight of this action critical. Politics in the state are fairly evenly split, with the Democrats stronger in the Chicago and East St. Louis areas and the Republicans in control in the Chicago suburbs and rural areas.
Asthma cost the state an estimated $485 million in 1998. Illinois has sought an aggressive approach to asthma, introducing comprehensive legislation for the past few sessions. Public Act 91-515 and Public Act 92-16 require the Department of Public Health (in conjunction with representatives of state and community-based agencies involved with asthma), to develop an asthma information system targeted at population groups with a high risk of suffering from asthma, specifically African Americans, Hispanics, the elderly, children, and those exposed to environmental factors that are associated with a high risk of asthma (20 ILCS 2310/2310-337).
Senate Bill 81
Amendments to the state's school code in 1999 allow for students to carry and self-administer asthma inhalers and medication with written permission from parents and doctors (105 ILCS 5/22-30). Another law prohibits smoking in day care facilities because may exacerbate or trigger an asthma attack (225 ILCS 10/5.5).
Bills from the 2002 legislative session also addressed asthma. Senate Bill 1716 amends the Department of Public Health Powers and Duties Law by adding a comprehensive, statewide asthma management plan to reduce the rate of hospitalizations due to asthma and to facilitate effective management of asthma. House Bill 827 (enacted) links air pollution to rising asthma rates and requests the federal government to offer more funds for public transportation.
Several local consortia exist that are conducting asthma education–such as patient and provider education–following NIH treatment guidelines. The Chicago Asthma Consortium focuses on reducing morbidity and mortality and enhancing the quality of life for people with asthma. It is made up of individuals, doctors and groups that have an interest in asthma issues. Another organization, the Chicago Asthma Surveillance Initiative (CASI), is funded by grants from the Otho S.A. Sprague Memorial Institute. CASI monitors and characterizes variations in asthma care throughout the Chicago area and surrounding counties.
Bills and Statutes
20 ILCS 2310/55.95
IL S.B. 81
This law directs the Department of Public Health, in conjunction with representatives of state and community-based agencies involved with asthma, to develop an asthma information program targeted at population groups with a high risk of suffering from asthma within the following groups: African Americans, Hispanics, the elderly, children, and those exposed to environmental factors associated with high risk of asthma.
ILCS § 47.05.012
The Michigan Legislature is a full-time legislature, commanding a strong presence in all facets of state government. Senators represent approximately 250,000 citizens, and House members represent about 91,000 citizens. The Legislature levies taxes, appropriates funds, enacts laws and provides oversight of executive branch agencies, including the Department of Health. This oversight requires the Legislature to audit agencies, review administrative rules (regulations), and approve the budget for each agency.
The Legislature has not enacted any substantial legislation to address asthma. Instead, because of its fiscal oversight responsibilities, it passed bills that earmarked funding for specific asthma projects. This forced the state agency to use this money to perform specific acts related to asthma, rather than using the funding for another purpose. Bills have been introduced to earmark appropriations for the state's epidemiology administration to implement an asthma intervention program, including surveillance, community-based programs, and awareness and education. Another bill sought $300,000 for an asthma intervention program–including surveillance, community-based programs, and awareness and education–requesting the department to seek federal funds as they are made available. Language such as this often becomes incorporated into the general appropriation bill, dictating that the state Department of Health perform that specific activity.
The state Department of Health has a legislative policy unit that provides information to the Legislature about public health, including asthma. (Medical costs related to asthma were approximately $224 million in 1998, and costs lost work and school days were approximately $170 million. Asthma project and program staff work through this policy unit, keeping separate the policy discussion and the program activities.
Bills and Statutes
Before the 2001-2002 session, only one statute addressed asthma in this state: Mich. Stat. § 336.104 exempts asthma inhalers from the restricted use list of chlorofluorocarbons.
Two bills from the 2001-2002 legislative session were passed into law: House Bill 4254 and Senate Bill 1101. Both bills appropriate money to the Department of Health to perform specific activities. HB 4254 appropriates funds to the epidemiology administration for an asthma intervention program, including surveillance, community-based programs, and awareness and education. S.B. 1101 appropriates $300,000 for an asthma intervention program, including surveillance, community-based programs, and awareness and education. It also requires the department to seek federal funds for asthma activities.
Oregon currently has a Democratic governor and a split legislature. The legislature meets in session only every other year for approximately six months. The Democrats have taken control of the Senate, but Republicans remain in control in the House. Oregon term limits were adopted as part of a constitutional amendment in 1992 that was ruled unconstitutional (on the basis that the original ballot measure addressed more than one subject in violation of the constitution).
The federal government funds all public health efforts in the state. General funds are sought but never appropriated. This means that the entire asthma program is funded by the CDC.
Asthma reportedly cost the state more than $125 million in 1998; $71 million in medical expenses and $54 million in lost work and school days.
The former governor, a physician, convened a task force on racial public health disparities, which identified asthma as a key concern. Because of this task force, the state's Department of Human Services (Division of Public Health) works on asthma with the task force members, five of whom are state legislators, including the vice-chair, Senator Avel Gordley.
Bills and Statutes
Information from the task force has lead Senator Gordley to introduce legislation, most notably Senate Bill 789 (2001). This bill sought to track the extent of asthma in "communities of color" and offer resources to respond to these cases.
The only law, Or. Rev. Stat. § 468.655, exempts asthma inhalers from a list of restricted aerosol sprays containing chlorofluorocarbons.
For the past decade, the Washington Legislature has been the most closely divided of all legislatures, with membership evenly divided among Democrats and Republicans. The Speaker's podium has been shared by both parties during one session, with Republicans in control in the first half of the session and the Democrats in control the second half. Throughout this time, Democratic Governor Gary Locke has worked closely with both parties, moderating his policies so as not to upset either party.
The Legislature also has been hindered by citizen's initiatives that have imposed term limits, tax limitations and budgetary restrictions. An initiative that passed in 1999 (Int. 722) required voter approval for any tax increases. Another repealed car licenses, the revenue from which the state had used to fund transportation. These two initiatives essentially depleted the state of any revenues, making funding of new programs (such as those to address asthma) nearly impossible.
Washington has no named staff dedicated to its asthma efforts, but spreads asthma activities throughout various local agencies and uses grants, universities and community programs to conduct asthma research, education and treatment. Asthma-related costs in the state were approximately $216 million in 1998.
The health department uses Medicaid resources to fund clinics in order to track asthma and coordinate community-level asthma efforts, such as bringing insurers and clinics together to tackle asthma issues. The health department used administrative match programs from Medicaid, along with money from the Robert Wood Johnson Foundation, to create the Allies Against Asthma Initiative. The initiative works to build coalitions of hospitals, schools, parents, health departments and community health centers to work together to improve asthma efforts. Allies Against Asthma also provides coordination of services and technical assistance to schools, works to improve quality of asthma treatment in clinics, and educates parents. Poor children with asthma are covered under a state medical program for children with special health care needs.
The Seattle-King County Healthy Homes Asthma Intervention Project, funded by the National Institute of Environmental Health Sciences, provides training for community health workers who will visit homes and teach residents how to make their homes healthier by reducing environmental health risks, including asthma triggers.
Washington currently has one epidemiologist at 15 percent time working on asthma surveillance at the state level. The health department managed, through a two-year CDC grant, to put state hospital discharge data on the Washington Lung Association Web site.
The Washington Department of Health is struggling to create a true asthma program and has received a grant from CDC to do so. State budget problems and a hiring freeze mean the department may not be able to hire personnel to fulfill the grant duties, and the grant may be rejected.
Bills and Statutes
The Legislature did not enact comprehensive asthma legislation, but it did pass, in the 2002 session, Senate Bill 6368, which states (among other items) that "asthma should first be considered for disease management programs." Senate Resolution 8426, which did not pass, identifies indoor mold as a trigger for people with asthma.
"Surveillance for Asthma -- United States, 19880-1999", MMWR 51, no. SS-1 (March 29, 2002). :
Practice standards adopted by the National Education and Prevention Program may be incorporated into amended regulations. Practice standards may include asthma regulation., enacted 1999 (1999) (20 ILCS § 2210/55.95), which passed but was not funded, required the state health department to convene a task force to assess priorities and provide a report summarizing state asthma needs. The health department used this report to apply for a three-year grant from CDC, which provided for the formation of working groups that deal with four topics–occupational asthma, school asthma, education and asthma surveillance. The grant also covered capacity building and some educational activities. Current surveillance activities consist of tracking asthma hospital discharge and mortality data. Emergency room visits are not tracked. Data are not collected by the department but are gathered from existing health information databases. The working groups have developed a comprehensive state asthma plan.
Allows a tax credit for 30 percent of money paid into a qualified child care plan; this includes money spent on arrangements for children suffering from asthma.
Implements an asthma reduction program contingent upon the appropriation of funds in the state's annual budget.
Requires the Department of Health and Services to monitor clinical and public asthma interventions and report successful and unsuccessful interventions.
Requires the Department of Health and Services to establish a surveillance program for the prevention of asthma.
A program providing prevention and reduction of asthma through assessment and intervention.
Provides funds for projects pertaining to the reduction of asthma through assessment, intervention and evaluation.
Requires the Department of Health Services to offer education on current asthma information, assist health care organizations to identify or develop asthma diagnosis and treatments, use current knowledge of asthma to reduce state burdens, and allocate money to promising asthma research organizations. No funding was appropriated for this program.
Requires the Department of Health Services to analyze asthma morbidity and mortality data, assess the burden of asthma on medical and economical resources, survey factors known to worsen asthma to estimate importance, assess asthma intervention, and related activities. , enacted 2001, enacted 2000 , enacted in 2001, may provide some asthma surveillance in the future through CalEPA and cooperation of universities. Asthma will be one of many diseases tracked under the Environmental Health Surveillance System that eventually will be created as a result of the bill. The legislation also creates a task force to investigate and determine how to best set up a comprehensive surveillance system. It does not provide funds for data collection, but asks the task force to report on the best methods and potential costs.