Home-Based Asthma Education and Environmental Interventions in Illinois: The Case for Sustainable Financing

Download report: RHA-SUHI-IDPH_Business Case_Asthma Care_ Final

Asthma education and environmental management are evidence-based strategies that reduce asthma-related emergency department (ED) visits and hospitalizations and reduce health care costs. Despite the economic benefits, reimbursement for these strategies tends to be lower and/or less comprehensive than other recommended asthma management approaches.

Our goal is to expand access to evidence-based, home-based asthma education and environmental interventions for Illinois residents living with asthma through sustainable financing mechanisms. While there are a number of mechanisms described in this report that are available to accomplish this, we recommend the following for immediate exploration:


  • Expand reimbursement for asthma educators, community health workers (CHW) and others currently outside of Illinois’ clinical licensure system;
  • Establish a Health Homes Program that incorporates asthma care best practices;
  • Apply for Section 1115 Research and Demonstration Waiver that includes home-based asthma education and environmental interventions;
  • Utilize reimbursement through existing Medicaid channels such as early and periodic screening, diagnostic, and treatment and administrative costs;
  • Amend contracts between state Medicaid and Medicaid Managed Care Organizations (MCO) to enable and provide guidance for the use of CHWs, and;


Encourage Medicaid MCOs to expand in-home asthma education and environmental interventions, by providing these services or reimbursing other providers.

Stock Asthma Rescue Medication in Schools

Download the Issue Brief – Stock Asthma Rescue Medication in Schools.

Stock asthma rescue medication in schools is a viable policy solution to help prevent the poor health outcomes that can result when a child experiences an asthma emergency at school, but does not have access to medication. After years of studying this critical policy gap, Respiratory Health Association (RHA) and Legal Council for Health Justice came together in 2017 to actively explore pursuing a stock asthma rescue medication policy in Illinois. In furtherance of that end, we are now proud to present this issue brief assessing the fit and feasibility of stock asthma rescue medication in Illinois schools.

This issue brief explores the burden of asthma and the asthma policy landscape in Illinois and outlines elements of stock asthma rescue medication policies and lessons learned from other states. It concludes with recommendations for adoption of a stock asthma rescue medication in schools policy for Illinois. It is our conclusion that a stock asthma rescue medication policy for Illinois schools could achieve a safer school environment for those living with asthma, and that the most appropriate framework for adoption ofsuch a policy would be via the state’s existing stockundesignated epinephrine auto-injector law in the School Code (105 ILCS 5/22-30). RHA and Legal Council for Health Justice hope this paper will serve as a useful educational tool for asthma policy stakeholders statewide to better understand the need for a stock asthma rescue medication policy and how one could be best implemented in Illinois.

Date of Publication: March 2018

Tobacco 21 Issue Brief

Download the Issue Brief: Raising the Minimum Legal Sale Age for Tobacco Products

Almost all smokers begin smoking during adolescence or young adulthood. Raising the minimum legal sales age (MLSA) is a viable tobacco control measure to curb adolescent and young adult uptake of smoking. As of January, 2017, more than 300 communities and 2 states have raised the MLSA to 21.1 In Illinois, six cities (Chicago, Evanston, Highland Park, Oak Park, Naperville, and Deerfield) have already raised the MLSA from 18 to 21 and a statewide law is currently being considered by the Illinois legislature.2 For Illinois policymakers, now is a critical time to act on tobacco use. 11,000 Illinois adolescents become new smokers each year; if these rates persist, 230,000 Illinois adolescents alive today will die prematurely from smoking.3 Raising the MLSA can reduce adolescent and young adult smoking initiation, help delay young adult transition from experimentation to regular smoking, and increase the odds of successful quit attempts. Reducing adolescent and young adult tobacco use will ultimately save millions in long-term health care costs and improve overall quality of life.

Young adulthood is a critical age for smoking initiation prevention

Age 18-21 is when most young smokers transition from experimental smoking to regular smoking.4  Older adolescents are much more likely to purchase their own cigarettes than younger adolescents, so it’s no surprise that the transition to regular smoking occurs during this time period. However, if a young person can make it into their twenties as a nonsmoker, their chances of ever becoming a smoker are significantly lower.  A 2015 report by the Institute of Medicine (IOM) concluded that raising the MLSA to 21 would likely prevent or delay initiation of tobacco use by adolescents and young adults.5 National data shows that only 10 percent of smokers start on or after age 19 and only 1 percent start on or after age 26.6 If measures are put in place to prevent adolescents and young adults from accessing tobacco until they reach that key threshold, then it is highly likely that they will remain nonsmokers for life. 

Raising the MLSA to 21 would keep tobacco out of schools

The majority of underage tobacco users rely on social sources like friends and family to get tobacco; however, 90 percent of those who supply cigarettes to minors are themselves under the age of 21.7 Raising the MLSA to 21 would mean that high school aged adolescents would be in separate social networks from those who are most likely to supply them tobacco. As more 18 and 19 year olds are in high school now than ever before, it is more important than ever to ensure that legal purchases of tobacco are outside of the secondary school age.4 While most MLSAs of 21 for tobacco have not been in place long enough for longitudinal studies, when the national drinking age was increased from 18 to 21, total drinking and binge drinking by high school seniors dropped by almost 40 percent.8

Raising the MLSA to 21 would reduce smoking prevalence among young adults

According to the IOM, if the MLSA were raised to 21, it would result in a 12 percent decrease in smoking prevalence by the time today’s teenagers become adults.5 The group that would see the biggest decreases in smoking prevalence would be 21-25 year olds.5 Analogously, when the national drinking age was raised to 21, it ultimately resulted in today’s 30 year olds consuming alcohol at a significantly lower rate than those of previous generations.8

Raising the MLSA to 21 can result in immediate and long-term health benefits

According to the IOM, an MLSA of 21 would result in immediate reductions in adverse physiological effects such as inflammation and impaired immune function.5  An MLSA of 21 would also likely result in decreased incidents of preterm births, low birth weight babies, and sudden infant death syndrome.5 In addition, economists estimate that if the MLSA were raised to 21, it would result in $212 billion in savings from decreased tobacco prevalence and savings in medical costs.10  Most importantly, a MLSA of 21 would ultimately likely result in reduction of smoking related mortality.5

Raising the MLSA to 21 would ease enforcement of the law by retailers

An MSLA of 21 would simplify age verification, since Illinois has a vertical license for persons under 21. Currently, retailers have to learn two different age verification approaches to cover liquor and tobacco.  Establishing 21 as the tobacco MLSA would mean retailers could rely on one method for checking all IDs.  In addition, it would likely increase compliance with the law, as high school students would have a harder time passing themselves off as 21 than 18.

Case Study: Needham, MA9

In 2005, the town of Needham, MA raised their MLSA from 18 to 21.  The effect this measure had on the citizens’ health was truly unprecedented.

  • Cigarette use among Needham High School students decreased by more than half, 3x as much as neighboring suburbs.
  • The rate of illegal sales to minors is 79 percent lower in Needham than the rest of Massachusetts.
  • The adult smoking rate in Needham is more than 50 percent lower than the rest of Massachusetts.
  • Not a single tobacco retailer went out of business.
  • No evidence of youth traveling to other towns to attempt to purchase tobacco.


Tobacco 21 Fact Sheet

Download the Tobacco 21 Fact Sheet.


TOBACCO 21 – The initiative to raise the tobacco purchase age from 18 to 21

Current tobacco use trends are driving new prevention strategies

  • In Illinois, 6,300 teens become new daily smokers each year.1
  • In suburban Cook County, 29 percent of high school seniors use tobacco products.2
  • While great strides have been made in tobacco prevention, declines in tobacco use rates have slowed and products like cigarillos, hookah, and e-cigarettes are now used at double the rate of cigarettes.2
  • Reducing teens’ access to tobacco products is a proven means to reduce current use and prevent initiation.

The age of 21 is important for prevention

  • 95 percent of smokers start before the age of 21.3
  • The majority of underage tobacco users get their tobacco from a peer; however, 90 percent of those suppliers are themselves under the age of 21.4
  • Drawing the line at 21 gets legal tobacco purchasers out of high schoolers’ social circles.

Tobacco 21 saves lives and improves health

  • The Institute of Medicine (IOM) projects that Tobacco 21 could reduce overall smoking by 12 percent by the time today’s teenagers become adults; the biggest declines in tobacco use would be seen among 15-17 year olds (25%) and 18-20 year olds (15%).5
  • Tobacco 21 would immediately improve community health by reducing inflammation, improving immune function, and reducing premature births and SIDS.
  • Based on the IOM report, Tobacco 21 in Illinois would save more than 8,000 lives.

The economic impact of Tobacco 21

  • Economists project that nationally, Tobacco 21 could save $212 billion in medical costs.6
  • Each year, tobacco use costs Illinois $5.49 billion in health care costs and $5.27 billion in lost productivity.1
  • The impact of Tobacco 21 on retail sales would be minimal since the 18-21 year old age group only accounts for 2 percent of overall tobacco sales.7
  • Applying tobacco economic data to IOM’s projected declines in tobacco use resulting from Tobacco 21, Illinois would save more than $2+ billion dollars in future healthcare costs. This doesn’t even include savings in lost productivity costs, which could be nearly as much.11

Tobacco 21 enjoys broad support across Illinois and the U.S., even from smokers!

  • A 2015 CDC study found that 75 percent of adults support Tobacco 21, including 70 percent of current smokers.8 A recent study also found that 68 percent of 18-24 year olds would support Tobacco 21.9
  • More than 220 cities across 16 states, plus the states of California and Hawaii, have enacted Tobacco 21.10
  • In Illinois, Tobacco 21 has already been adopted by Evanston, Chicago, Oak Park, Highland Park, Naperville, Deerfield and Maywood, and is being considered by dozens more communities.


1 Campaign for Tobacco-free Kids. (2017). The Toll of Tobacco in Illinois. Available at http://www.tobaccofreekids.org/facts_issues/toll_us/illinois.

2 University of Illinois, Center for Prevention Research & Development. (2016). Illinois Youth Survey. Available at https://iys.cprd.illinois.edu/.

3 Centers for Disease Control and Prevention. (2014). Youth and Tobacco Use [fact sheet]. Available at http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/.

4 Berman, M., Crane, R., Hemmerich, N. (2015). Running the Numbers – Raising the minimum tobacco sales age to 21 will reduce tobacco use and improve public health in Franklin County, Ohio. The Ohio State University, College of Public Health, Columbus, OH.

5 Institute of Medicine of the National Academies. (2015) Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Available at www.iom.edu/tobaccominimumage.

6 Counter Tobacco. (2015). Raising the Minimum Legal Sale Age to 21 [fact sheet]. Available at www.countertobacco.org/raising-minimum-legal-sale-age-21.

7 Winickoff, J.P., Hartman, L., Chen, M.L., Gottlieb, M., Nabi, E., DiFranza, J. (2014). Minimum Retail Impact of Raising Tobacco Sales Age to 21. Am J Pub Health, 104(11): e18-e21.

8 King, B.A., Jama, A.O., Marynak, K.L., Promoff, G.R. (2015). Attitudes toward raising the minimum age of sale for tobacco among U.S. adults. Am J Prev Med, 49(4):583-588.

9 Morain, S.R., Winickoff, J.P., Mello, M.M. (2016). Have Tobacco 21 Laws Come of Age? N Engl J Med, 374: 1601-1604.

10 Campaign for Tobacco-free Kids. (2017). States and Localities that have Raised the Minimum Legal Sale Age for Tobacco Products to 21. Available at http://www.tobaccofreekids.org/content/what_we_do/state_local_issues/sales_21/states_localities_MLSA_21.pdf.

11 Campaign for Tobacco-free Kids. (2017). Comprehensive Statewide Tobacco Prevention Programs Save Money. Retrieved from https://www.tobaccofreekids.org/assets/factsheets/0168.pdf.

Issue Brief – ACA is Good for Lung Health

Download the Issue Brief – Affordable Care Act is Good for Lung Health PDF.


Executive Summary

In March 2010, the Patient Protection and Affordable Care Act (ACA) was signed into law. Since that time, more than one million Illinois residents gained insurance coverage through either the Health Insurance Marketplace or the Medicaid Expansion, and the uninsured rate in Illinois has fallen by 49 percent.

With ongoing threats to the ACA from Congress, advocates are taking a close look at how its possible repeal will impact vulnerable populations, both locally and nationally, with a particular focus on the numbers who will lose their health care coverage.

With this brief, the Respiratory Health Association (RHA) focused on why a repeal of the ACA would be bad for lung health. Several provisions of the ACA have been particularly valuable to efforts to prevent and improve health outcomes for people living with asthma and other respiratory conditions; we highlight four of those:

  • Dependent Coverage for Young Adults: Reducing Asthma Emergency Room Visits
  • Medicaid Expansion: Improving Quality of Asthma Care
  • The Prevention and Public Health Fund: Supporting Tobacco Control
  • Requiring Coverage for Pre-Existing Condition: Making Treatment Affordable

Date of Publication: May 2017


If you have questions or would like additional information about the Affordable Care Act and lung health, please contact Erica Salem via email [email protected] or by phone (312) 628-0235.