The Low Income Home Energy Assistance Program (LIHEAP) Health and Safety August 16, 2016

Leon Litow, Division of Energy Assistance, OCS Administration for Children and Families, HHS [email protected]

1995 Chicago Heat Wave739 heat-related deaths over 5 days

Staying Healthy and Safe at Home • Affordable home energy burden • Energy to cool or heat one’s home; electricity to operate home energy equipment • Maintenance, repair, replacement of home energy equipment

Unaffordable Home Energy • Raising or lowering indoor temperatures to unsafe levels or cutting back on food, medication, etc. • Resorting to unsafe methods to keep homes warm or cool • Utility shutoffs and/or dry fuel tanks; electricity not available to operate home energy equipment • Home energy equipment failure or damage from natural disasters

LIHEAP Basics •

Block grant flexibility for LIHEAP grantees to design programs to meet home energy needs

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LIHEAP grantees-50 states and District of Columbia, Indian tribes or tribal organizations, and U.S. Territories

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Not entitlement program – $3.4 billion funding for Federal Fiscal Year 2016

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Priority for vulnerable households at risk for hypothermia (too cold) or hyperthermia (too hot) -Elderly, persons w/disabilities, & young children

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Priority for high energy burden households – cutting back on basic necessities

Low Income • Household income adjusted by household size percent of poverty level – no lower than 110% poverty; no higher than 150% poverty or 60% state median income (can be expressed as % of poverty) • Households in which at least 1 person is receiving TANF, SSI, SNAP, and certain Veteran benefits • Grantee’s can use additional program criteria such as receipt of a utility disconnect notice or meeting a resource or asset test

Home • Single/duplex dwelling, mobile home, multi-unit building, etc. • Owners • Renters

Energy to heat or cool home– regulated and unregulated fuels

Assistance • Assistance with payment of part of home heating / cooling costs – usually paid directly to energy suppliers • Energy crisis assistance – funds or in-kind assistance for weather-related, supply shortage emergencies and other household energy-related emergencies -– Reasonable amount of crisis funds reserved until March 15th – After applying for energy crisis benefits implementation of 48/18 hour rule if a household is eligible for such benefits

Assistance • Weatherization and energy-related home repairs (install or repair window and door screens) •

Installing or repairing home energy equipment

• Home energy education • Budget counseling – payment plans

Lessening the Risk of Heat Waves • Establish cooling centers and coordinate with community emergency response teams • Loaning or giving air conditioner units • Provide higher crisis benefits for electric bills to help offset higher demand for air conditioning

Lessening the Risk of Heat Waves • Provide targeted outreach to identify households at greatest risk to heat • Provide client education about how to keep their homes cool during extreme heat wave • Provide PSAs on critical information about emergency resources, how to recognize signs of heat-related illness, and steps to stay cool

Where to Apply • Local energy assistance office--Community Action Agencies, AAAs, Department of Social/Human Services, Health Department • The National Energy Assistance Referral (NEAR), a free service providing information on where to apply for LIHEAP. 1-866-674-6327or [email protected] • OCS’ LIHEAP Grantee Directory at OCS website www.acf.hhs.gov/ocs/programs/liheap • Health officials, Red Cross, Salvation Army, Consumer Protection, local government – Utility Fuel Funds

Some Resources • National Center for Benefits Access, March 2016, LIHEAP 101 • LIHEAP Clearinghouse, March 2014,LIHEAP 101 What You Need to Know • U.S. Office of Community Services, LIHEAP Brochure (in English and Spanish)

Public Health Implications of LIHEAP for Older Adults

CDR Jonathan White Administration for Children and Families

Key Topics • Describe home energy security in the context of social determinants of health. • Identify key mechanisms for indoor temperature and air quality related to affordable heating and air conditioning to affect human health. • Discuss energy assistance as a public health intervention in the context of risks faced by older adults and multigenerational households led by older adults

Social Determinants of Health

Human Services & the Social Determinants of Health Factors Impacting Population Health

Physical Environment (10%) Health Care (20%) Health Behaviors (30%) Social & Economic Determinants (40%) University of Wisconsin Population Health Institute (2010)

Socioeconomic Determinants of Health • Socioeconomic determinants of health are the foundation of population health. • Interventions in the social and economic conditions that affect health have the largest population-level impacts.

Centers for Disease Control & Prevention (2015)

Energy Assistance Programs One of the Best-Kept Secrets in Public Health

How Can Extreme Temperatures Affect Human Health? • • • • • • • • • • • • • • •

Heat injury (heat cramps, heat exhaustion, and heat stroke) Cold injury (hypothermia and frostbite) Ischemic heart disease Cardiovascular disease Stroke Asthma Allergies Chronic obstructive pulmonary disease (COPD) Respiratory disease Mosquito-borne illness Environmental pollutant exposures Accidents and burns Dehydration Food-borne illness Behavioral health/stress

Who is at heightened risk? • Children (0-5) • People with certain chronic health conditions • Individuals experiencing homelessness • Low-income individuals and families • Older adults

Heat Injury Risk • Outdoor Temperature Risk • Indoor Temperature Risk • Economic vulnerability raises both types of risk

Cold Injury Risk • Outdoor Temperature Risk • Indoor Temperature Risk • Economic vulnerability raises both types of risk • Older adults have slightly higher outdoor temperature risk and much higher indoor temperature risk

Older Adults at Risk Cold-Related Injuries • Older adults are at higher risk than of indoor cold injury • Most indoor hypothermia deaths in the United States occur in older adults living alone

Heat-Related Injuries • Older adults are at higher risk of indoor and outdoor heat injuries • Heat waves cause more deaths in a typical year than any other natural disaster—and 80% of deaths and hospitalizations are people over 60

Mechanics of Temperature Risk Pre-Existing Health Risks Built/Natural Environment

Outdoor Temperature

Age-Related Risk

Temperature Health Risk

Home Energy Insecurity

Air Conditioning and Health • The largest study yet attempted in the U.S. which looked at California from 1999 to 2005… “…observed a significantly increased risk of hospitalization for multiple diseases, including cardiovascular disease, ischemic heart disease, ischemic stroke, respiratory disease, pneumonia, dehydration, heat stroke, diabetes, and acute renal failure, with a 10º [Fahrenheit] increase in same-day apparent temperature. They also found that ownership and usage of ACs significantly reduced the effects of temperature on these health outcomes, after controlling for potential confounding by family income and other socioeconomic factors.” -- Ostro, Green, Malig, & Rasu 2010, Am J Epidemiology 172(9)

Indoor Air Quality • Economic disadvantage and IAQ risk • Energy security, extreme heat/cold, and IAQ • Key factor in respiratory disease burden for older adults and multigenerational households with older adults – Asthma (in children and adults) – Allergies (in children and adults) – COPD (in older adults)

Weatherization & Indoor Air Quality • The Environmental Protection Agency (EPA) has determined that weatherization improvements to a home, if they are not accompanied by steps to protect Indoor Air Quality (IAQ) may lead to increased health risks for people in the home. • Weatherization “tightens” the home, decreasing airflow in and out of the house. This increases the daily exposure of residents to indoor air pollutants, unless mitigated. • EPA has established recommendations on public health mitigation steps to keep weatherization safe and healthy. These are worth reviewing or sharing as part of LIHEAP Weatherization Programs.

Environmental Protection Agency: http://www.epa.gov/indoor-air-quality-iaq/protocols-home-energy-upgrades

Climate Change Health Risks “The populations most vulnerable— children, elderly people, those living in poverty, people living in certain geographic areas and people with underlying health conditions—are at even greater health risk from climate change.” -- Luber, Knowlton, & Beard (2014), CDC Public Health Grand Rounds

High Risk Clients & Energy Assistance • “High-Risk” Clients and Eligibility Determinations – “High-Risk” populations for purposes of LIHEAP by statute • Includes older adults – “High-Risk” populations for adverse indoor temperature health outcomes based on available scientific evidence – Implications of science for eligibility prioritizations—options for state program policies

Public Investment and Health Care Cost Savings • Access to home energy can significantly reduce ER visits • ER admissions represent one of the highest-cost health care services and are a focus of cost reduction efforts by HHS • A critical area for emerging and future investigation: are there net public savings (in Medicaid and Medicare costs) created by investments in energy assistance?

Partnerships and Paths Ahead • To address heating/coolingrelated risks to older adult clients, improved outcomes are likely with strong partnership between aging services agencies and… – – – – – –

Energy assistance programs Community Action Agencies Public health authorities Clinical health care systems Bridge organizations Environmental health & justice groups

Questions?

CDR Jonathan White, Ph.D., LCSW-C, CPH Senior Adviser for Strategic Initiatives Immediate Office of the Assistant Secretary Administration for Children and Families [email protected]