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Many DC children are struggling to breathe. Is bad communication to blame?

Author: Marla McDaniel

| Posted: April 18th, 2014

AC_header-01Could simply fixing gaps in communication between doctors and schools be a key to reducing the impact of asthma on poor kids?

A lot of research shows that not getting the right—or consistent—care causes conspicuous health disparities that fall neatly along racial, ethnic, and economic lines. For many kids with asthma, their condition is managed not by routine care, but by regular emergency trips to the hospital while struggling to breathe.  Unfortunately, if you’re a low-income African American or Latino child with asthma in DC, your asthma experiences are more likely to include one of those terrifying trips.

Access, quality of care, and poverty are part of the story, which my colleagues and I highlight in a series of blog posts and our new report. But our report also highlights the problems created by miscommunication—or worse, no communication—between the professionals and caregivers children need most to manage this chronic and life-threatening illness. Could focusing on communication make things much better for kids?

It takes a team to manage children’s asthma. It takes medical professionals, parents, schools, and the patients themselves.  But our report finds several places where communication lapses routinely occur.AC_dots-03Doctors need the time to educate parents and patients about the different kinds of medications and make sure they understand that some need to be taken every day indefinitely, no matter how the child is feeling. IMPACT DC , the Children’s National Health System program that sees patients who come to the emergency department for asthma-related issues tries to tackle this problem.AC_dots-04But to keep children well, IMPACT DC needs to be able to hand off the care to community providers who can take the time to follow up with parents and patients to make sure that they are following these instructions. And parents need to understand and help their kids stick with the medications and care plan—and to speak up when they are confused.AC_dots-05Finally, doctors and parents need to make sure that the adults at school—where kids spend most of their daytime hours—know about each child’s asthma diagnosis and individual plan. School nurses can help kids remember to take their daily medications and use their emergency inhalers before exercise—and when they feel symptoms coming on.

We know how to manage children’s asthma, and we know everyone we need on the team. Now we need to make sure the team works together. AC_footer-02

Illustration by Daniel Wolfe, Urban Institute. 

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How being poor in DC makes kids’ asthma worse

Author: Nicole Levins

| Posted: April 16th, 2014




In the United States, more than 7 million children suffer from asthma. But in spite of the chronic and sometimes life-threatening nature of the disease, most of these kids lead active, healthy lives.

That’s not the case for some low-income families in Washington, DC. Asthma’s a big problem for the relatively small city, where the proportion of children suffering from the condition is one of the greatest in the nation.

Fortunately, DC is also home to IMPACT DC, an emergency department-based intervention that has helped reduce the number of emergency room visits from low-income children with asthma. But despite the program’s effectiveness, lots of DC kids and caregivers are still struggling to manage the disease.

So, how can we help everyone breathe a little easier? Urban Institute researchers, led by Marla McDaniel, teamed up with IMPACT DC to interview 33 players involved in asthma treatment—from parents to primary care physicians to IMPACT DC’s educators—to figure out why it’s so hard to treat asthma among DC’s poorest kids. In their own words, here are five potential factors.

Limited time

Low-income caregivers are often forced to balance parenting duties with inflexible jobs and non-standard working hours. Though children’s medical needs come first, it’s sometimes at the expense of the job that helps pay for the treatment.

“…I had to quit jobs before because she had an asthma attack three days in a row… They won’t let me take time off, so I quit.” - Caregiver

For educators and health care professionals, limited time with patients and caregivers makes it difficult to address all concerns and answer all questions.

“…Time is a huge factor... In most primary care visits, you have 15 minutes to cover the entire health of the child… the amount of time physicians have for health education is almost none...” - Asthma educator

Lack of management

Who’s in charge of managing a child’s asthma treatment? For children with multiple caregivers, there’s often no one person ensuring that the child sticks to the treatment plan.

“[Having] multiple caregivers is a strong indicator of poor adherence, for obvious reasons. Usually only one caregiver comes [to] the visit, and frequently it’s the caregiver with the most time on their hands...  But it’s not necessarily the one with the most power in the family dynamic...” - Asthma educator

Sometimes, the responsibility is left up to the child.

“When I am at work then she call[s] me. 'Mommy, it’s time for medicine,’ and I say, ‘OK, go do your thing.’ She turns it on and uses it… She knows what she[‘s] doing… But my son, I can’t trust him with nothing! He’s only four.” - Caregiver

Difficulty accessing care

In DC, the best doctors and specialists are often out of reach for those with low-incomes—located in the less transit-oriented suburbs and Northwest.

“[For low-income families in poor neighborhoods,] getting to the doctor is harder. Once you get to the doctor, you wait longer, so you’re less likely to go… And you lose an entire day of work.  And these are the families who also tend to have the least flexible work schedules.” - Asthma educator

“Unhealthy” housing

Cheaper, older apartments—where many low-income DC families live—can host a number of asthma triggers.

“We don’t have a thermostat to control the heat in the basement apartment.  It gets so hot in there and we have to keep the windows open all the time.” - Caregiver

“We had to move because there was something in the carpets [that was triggering asthma attacks]…” - Caregiver

Lack of adequate health coverage

Most doctors agree that Medicaid and other insurers could do a better job covering routine care for low-income patients, which could go a long way in preventing attacks and hospital visits.

“…Not all of the payers are allowing kids to have two inhalers at the same time. We have one for home, one for at school, and they don’t pay for both…” - Primary care physician

“One of the things [Medicaid] could do better is managing claims and hiring educators to look at claims to see who is filling what prescriptions and when and how often. They could then work with those families when they see prescriptions are not being filled.” - Primary care physician

“It’s much more cost-effective for insurance to keep [a] child out of the ER. There’s a lot of benefit for the insurance.” - Primary care physician

Photo from Shutterstock.

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What can we learn from the demographics of DC’s unique voting precincts?

Author: Rob Pitingolo and Peter Tatian

| Posted: March 31st, 2014

Tomorrow, District of Columbia residents will go to the polls to vote in this year’s primary election. Voters will decide which candidates will represent their party for Mayor, at-large Councilmember and, in some places, Ward Councilmember, among others, in November’s general election.

As results begin to roll in on Tuesday evening, many will wonder how candidates fared in different neighborhoods. What do the places that preferred incumbent Mayor Gray look like? How are they different from the neighborhoods where Muriel Bowser, Jack Evans, Tommy Wells, and other challengers won the most votes?


Until now, this was a difficult question to answer. Washington, DC’s voting precincts are unique areas used for tabulating and reporting election results. They don’t map cleanly to Census Tracts, Advisory Neighborhood Commissions, or other neighborhood-level geographies. The reference map provided by NeighborhoodInfo DC shows how these geographies, including voting precincts, fit together (or don’t).

The DC Board of Elections will publish vote counts by precinct in the days following the primary. While the election winners are based on total votes cast across the city, looking at the results by precinct can help us understand better where different candidates received the most support.

To help with this, NeighborhoodInfo DC has released data for voting precincts in time for the primary election. Anyone can download these data to look at the demographic makeup (including metrics like race, age, and income) for each of the District’s 143 voting precincts. These data allow analysts to understand the population of each voting precinct, though they don’t shed light on the demographics of actual voters themselves.

Our hope is these voting precinct data will help those who want to analyze and understand tomorrow’s election outcomes, as well look ahead toward future votes.

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How good are DC's schools?

Author: Austin Nichols

| Posted: March 11th, 2014

Public schools in DC have gained ground on national tests over the past 15 years, but much of that gain is due to the changing demographic composition of DC’s student body. Parents’ income and education are primary determinants of student performance, and as the income and education of DC residents has improved, so have incoming students’ scores. Comparing NAEP scores over time without accounting for incoming class scores is mere jackaNAEPery, and comparing proficiency levels is no better.

The best measure of school quality is how much students learn: their improvement from incoming to outgoing scores, not how well they test at just one point in time. Measuring how much students learn over time is difficult, and measures of teacher impact and school-specific test score growth compare only how well DC public school students do relative to other DC public schools students. This leads to relative rankings only, not measures of how DC public schools as a whole are improving, as do most other measures of value added by schools.

So how can we gauge how much a given school improves students’ scores relative to other schools? Using the median growth percentile (MGP) may be the best bet. Each student’s growth percentile score is equal to the percentage of comparable students districtwide who performed worse on a later math and reading exam. The school’s score is then the typical student’s score.

For example, imagine Nicole earns a 45 on a math exam at the end of 4th grade. Nicole’s comparison group is students who also scored around 45 on that exam. Now imagine that at the end of 5th grade Nicole scores a 52. If that 52 is better than the scores of 70 percent of her comparison-group peers, then Nicole’s growth percentile is 70, which is a measurement of her relative growth. From there we can figure out each school’s MGP, the middle growth percentile of all of that school’s students.

A typical school will have a median growth percentile of 50, while 70 means a school is doing substantially better than a typical school and 30 means a school is doing substantially worse. So we can say one school is better than another if its MGP is higher, meaning that at least the typical growth level is higher at one school than the other (it could still be the case that the lower-ranked school serves a specific subgroup much better than the higher-ranked school).

The main problem is that these scores are fraught with measurement error, so rarely can we say with confidence that one school is better than another school. For example, Bancroft was in the top third on math MGP for 2011-12 and H.D. Cooke was in the bottom third, but the two math MGP scores are statistically indistinguishable (their scores’ margins of error overlap).

The graph below shows each school’s math versus reading MGP scores for 2011 and 2012. A box around each dot indicates the range of statistically indistinguishable values for both math and reading in that year (2013 data were not released with the ranges). This way, we can compare the score both to other schools and to the typical school with a score of 50 (whose dot would be at the intersection of the math and reading lines at 50). Each school’s box overlaps with the boxes of many other schools, and any two schools whose boxes touch are statistically indistinguishable. In many cases, many dots representing best guesses for other schools will be included in the range for a given school, for example Barnard ES (Lincoln Hill) in the graphic below. Whenever we compare schools, we should remain appropriately skeptical about the relative strengths of signal and noise in these data.

So what can we say? Charter schools (in blue) tend to have higher growth scores, but traditional public schools (in dark gray) are overrepresented at both the highest and lowest ranks. The main difference between the sectors is that charters tend not to be observed among the lowest-performing schools, suggesting that the worst charters are better than the worst traditional public schools.

But there are surprises in both sectors. For example, what is the best high school in town? Ranked by the MGP for math, it is Thurgood Marshall Academy (a charter), east of the Anacostia, with McKinley Technology High School (DCPS) in Eckington running a close second. Only a handful of other high schools are statistically better than average on math in both years, but the sought-after high schools Wilson and School Without Walls are not on that list.

Among elementary schools, the top performers are scattered around the city, for example Ross in Dupont, Stanton in far Southeast DC, Tubman in Columbia Heights, Watkins on Capitol Hill, and Stoddert in Glover Park. The top middle schools are the KIPP DC AIM and KEY academies, with Cesar Chavez Prep and DC Prep’s Edgewood Middle charters not far behind. The highly regarded Deal Middle School in Ward 3 barely squeaks out a statistical advantage over the typical school.

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Protecting the Future of Affordable Housing by Strengthening the FHA

Author: Taz George

| Posted: March 1st, 2013

The Federal Housing Administration (FHA), which insures mortgages to help underserved borrowers, is still feeling the sting of the foreclosure crisis. The agency has lost money on troubled loans, particularly those that originated in 2008 and 2009 during the housing bust. Because of these losses, the FHA does not have enough in its insurance fund to cover all expected claims over the next 30 years, according to its November actuarial report. But the agency is still strong and still has a crucial mission to carry out. So, what should be done to get FHA’s finances back in order and prevent unnecessary losses in the future?

Enabling the agency to better manage, price, and mitigate risk would help, Urban Institute President Sarah Rosen Wartell advised Thursday in her testimony before the Senate Committee on Banking, Housing and Urban Affairs.

Wartell proposed innovative strategies to allow FHA to respond effectively to rapidly changing market conditions. She noted that, unlike private mortgage insurers, FHA’s ability to mitigate risk is constrained by complicated rulemaking and legislative processes. For example, for three years, the agency has been trying to strengthen the indemnification process, which requires congressional approval of two key authorities: to force lenders whose loans do not meet agency guidelines to reimburse taxpayers for the cost of those claims, and to immediately stop known irresponsible lenders from originating FHA-insured loans. Despite near consensus among experts about the need for these additional authorities, FHA has had to continue insuring excessively risky loans without collecting appropriate penalties as it awaits required input from Congress.

Wartell’s recommendations included granting the HUD secretary emergency powers, subject to congressional oversight, to suspend or modify FHA insurance programs in times of crisis to quickly avert these risks. Additionally, she called for directing the HUD secretary to develop and continuously improve early warning indicators of risk and allowing FHA to offer higher salaries to recruit talented staff that can develop and run analytical and risk management systems.

While Wartell’s testimony offered concrete proposals, policymakers are sure to encounter more questions as they consider how to address FHA’s challenges: What does FHA look like in the context of broader housing finance system reform? How will changes to FHA’s practices affect private insurers’ market share? And most important, how can FHA best improve its financial situation while continuing to provide underserved borrowers with access to credit and serving as a countercyclical force in times of crisis? The next few months will be critical for the future of American housing.

The Urban Institute is partnering with Next City, Bank of America, the Penn Institute for Urban Research, and the National Building Museum for a panel discussion on “The Future of the FHA and Affordable Housing in Cities.” Sarah Rosen Wartell and other key leaders in housing, lending, real estate, and government will discuss the future of housing policy by examining the FHA’s role.

To learn more about housing finance system reforms, see the Bipartisan Policy Center’s Housing Commission report, which outlines a possible blueprint for changes.

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Families with Young Children Are Investing in the District's Public Schools

Author: Jennifer Comey

| Posted: February 22nd, 2013

It is good news indeed that the number of students enrolled in traditional DC Public Schools (DCPS) and public charter schools increased by 5 percent between October 2011 and October 2012, the fourth consecutive annual increase. Those familiar with the District know that the sizeable public charter sector—second only to New Orleans—played a significant role.

Public charter school enrollment exploded since its start in 1996. Today, 57 charter schools on 102 campuses serve approximately 43 percent of all District public school students. And more charters are expected to open in 2013 after approval by the DC Public Charter School Board.

But DCPS enrollment has recently stabilized as well, which is an accomplishment in the midst of tough charter competition and recent school closings.

Looking at the total student enrollment by grade, we see that the expansion of early childhood grades drove this overall increase. DCPS and public charter schools expanded slots for preschool (which serves 3-year-olds) and prekindergarten (4-year-olds) by almost 7,000 students between 2001 and 2012. These grades are not compulsory in the District but reflect the commitment and investment the city has in early childhood education to later improve children’s educational outcomes.  According to a recent Washington post article, preschool and PreK enrollment in public schools and other programs offering free early childhood education approaches “universal” enrollment  (approximately 85 percent of age-appropriate children are enrolled).

Also promising is that the early childhood influx that started in 2008 now extends to 1st grade with a new uptick in 2nd grade as well. The fear that the new preschool and prekindergarten students would leave after receiving free “daycare” has not occurred, yet. Instead, DCPS and public charters are working to keep these families by expanding already successful schools and offering a wider array of programming such as Montessori, language immersion, and “expeditionary” learning. The back-to-the-city movement appears to have contributed as well. Many new young families want to remain in the District, reduce their work commute, and invest in their communities. Families of young children are enrolling and getting involved in public schools.

Stay tuned for future posts that show where schools experienced some of the largest public-school enrollment increases.

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Yes, Mayor Gray, It’s time for a Prosperity Dividend for the District

Author: Mary Cunningham

| Posted: February 14th, 2013

Homeless man sleeping in John Marshall Park, NW Washington, DC. Photo by: Flickr users rjs 1322 used under a Creative Commons License (cc-by-sa 2.0)

Homeless man sleeping in John Marshall Park, NW Washington, DC. Photo by: Flickr users rjs 1322 used under a Creative Commons License (cc-by-sa 2.0)

It is difficult to reconcile the recent reports of 600 children living in improvised shelters in abandoned DC General Hospital buildings with the District’s year-end surplus of $400 million.  As someone who has studied the lack of affordable housing in DC for more than a decade, I agree with Mayor Gray: it’s time to pay out a "prosperity dividend."

Living in a resilient, booming city has meant great things for middle- and upper-income DC residents: ramen on H Street, oysters at Union Market, ice-skating at Canal Park, and events at Living Social. New amenities like these have made the city more attractive. People want to live and play in DC, and they are buying houses in Bloomingdale, Hill East, Trinidad, and along H Street.

At the same time, the city’s prosperity has put pressure—in the form of rising rents—on its poorest families. Most are rent burdened, so even a minor fluctuation in salary or benefits puts their housing at risk. The result: homelessness among families in DC has steadily risen every year for the past five (increasing 72 percent during that time). Stimulus programs that helped slow the rise, like the Homelessness Prevention and Rapid Rehousing Program (HPRP), are long gone.

The Washington Post’s picture of two adorable babies sharing a stroller to keep warm is likely to pull on some heartstrings—and it should. However, budget-minded policymakers should also know that the temporary option isn’t necessarily the cheapest option.  Shelters can cost significantly more than subsidizing rent. (See this HUD study.) Some homeless families languish in shelter and transitional housing for months, or even years, a very costly response. So the lack of action is not only morally repugnant; it is bad policy.

In his state of the city address, Mayor Gray announced a $100 million commitment to affordable housing. It is unclear what he plans to do with those funds, since his office has yet to share any formal strategy. If the mayor wants to help the 600 children and their families living in DC General, along with other homeless families throughout the city, here is where he should put the money:

  • $10 million for a new Homelessness Prevention and Rapid Rehousing Program (HPRP). During the recession, HPRP provided DC $7.5 million from the federal government to fund housing and supportive services. The program ended in September 2012, leaving an enormous gap to fill. This model is critical for helping families pay the rent and avoid long, costly stays in the shelter system.
  • $40 million for the Local Rent Supplement Program. This established program, which operates similarly to the housing voucher program, is ready to provide subsidies to families so they can rent housing in the private market. All it needs is more money. For the past several years, funding for local rent supplements has hovered between $12 and $19 million and has served only a fraction of the need.
  • $50 million for the Housing Production Trust Fund. In recent years, the Housing Trust Fund has been an unstable source for affordable housing preservation and production. It is time to shore up resources, set preservation and production goals, and build capacity among nonprofit housing developers, especially ones that develop permanent supportive housing for poor, disabled families and veterans.

A surplus of this size leaves no excuse. It is time to act.

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Taxation in DC, The Unofficial 51st State

Author: Katherine Toran

| Posted: February 7th, 2013

I recently had a conversation with a friend who was moving and said she preferred to live in Maryland than in DC because DC residents pay higher taxes. She wasn’t the first local to tell me that. But is this claim true?

It appears in this case, conventional wisdom is out of touch with the facts. The DC Fiscal Policy Institute compared hypothetical families earning $50,000, $100,000, or $200,000 and found that, in most cases, DC residents have lower combined income and property taxes than Maryland or Virginia residents. The primary reasons cited are lower property tax rates and benefits such as the homestead deduction, which combine to limit homeowners’ taxable assessment.

However, the DC Fiscal Policy Institute’s study focuses on middle-class families, and notes that for low-income families, taxes are higher in DC than in Maryland and are similar to Virginia. The DC Chief Financial Officer’s most recent comparative tax study confirms that DC taxes are lower relative to neighboring jurisdictions for families earning $50,000, $75,000, $100,000, and $150,000. This does not hold true at the $25,000-income level, where DC taxes are middle-of-the-pack.

So, it would appear that whether it is preferable to live inside DC or just outside of it depends on your income level.

A report from the Institute on Taxation and Economic Policy, comparing tax systems in all 50 states, finds that taxpayers in DC with incomes of $20,000 to $252,000 pay about 10 percent of their incomes in property, sales, and income taxes. Conversely, the top 5 percent pay about 8 percent of their income. On the upside, those earning below $20,000 pay the lowest rate, 6.2 percent.

The reason for this regressive taxation on moderate-income families is DC’s reliance on sales and excise taxes, which fall heaviest on low-income families. Low-income tax benefits, particularly DC’s earned income tax credit, offset this regressivity for the poorest families, but not for those of low to moderate income.

Conventional wisdom and the current US tax code suggest that Americans on both sides of the aisle favor a progressive tax system, even if they disagree on the extent. Regressivity creeps into the tax code through taxes other than the income tax. DC is not alone in this problem, or even an egregious example: the Institute on Taxation and Economic Policy report finds nearly all state and local tax systems take a greater share of income from middle- and low-income families than from the wealthy. In DC, the sales, excise, and property taxes are regressive enough to overbalance a progressive income tax.

Not only DC but other state and local jurisdictions could stand a comprehensive review of how taxes are collected and who pays. However, in neither quantity nor quality is DC remarkably different from its neighbors in taxation.

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Explore D.C. Housing-Market Changes With New Interactive Tool

Author: Graham MacDonald

| Posted: February 5th, 2013

A new tool released by NeighborhoodInfo DC provides detailed, ward- and neighborhood cluster-level information on condominium and single-family home sales in the District of Columbia from 1995 to 2011, with data updated annually. The interactive map and data display allows for analysis across neighborhoods over time. For those interested in conducting their own detailed analysis, the full dataset can be downloaded.

This interactive tool allows people to explore changes in the city’s housing market during the housing market bubble, the recent recession, and the current recovery. Despite declining home sales throughout the District from 2005—just before the height of the nation’s housing boom—to 2011, median sales prices for single-family homes have held steady and even increased slightly through the recession and the start of the recovery. In contrast, both sales volume and median condo prices fell significantly between 2005 and 2011.

However, these broad trends mask significant disparities between wards and neighborhoods. (Click the image below to go to the interactive tool.)


Home prices went up in all wards during the housing market bubble, followed by declines during the recession. But in places such as Wards 2 (downtown), 3 (Northwest), and 6 (Capitol Hill), the price increases started sooner and lasted longer than in other areas, such as Wards 7 and 8 (east of the Anacostia). Later price declines were also steeper in Wards 7 and 8 (27 to 28 percent lower between 2007 and 2011) than in Wards 2, 3, and 6 (7 to 10 percent lower).

Differences among neighborhoods are also striking. Some neighborhood clusters, such as the Near Southeast–Navy Yard cluster in Ward 6, have experienced large gains in sales prices for median single-family homes (49 percent) and condos (27 percent) between 2006 and 2011. On the other side of the coin, some of the hardest hit neighborhoods, such as the Ivy City–Trinidad cluster in Ward 5, experienced large drops in single-family median prices (-39 percent) during that same time period.

These data can tell many other stories, and we invite you to explore the interactive tool and download the data to find your own. NeighborhoodInfo DC will update these maps with new sales data as they become available. We expect the 2012 data to be added by early summer. Sales data for single-family homes are also available in NeighborhoodInfo DC’s Neighborhood Profiles, along with additional information on housing, foreclosures, demographics, and many other indicators across different geographies. Other local interactive features on the site include our map of foreclosures in Prince George’s County.

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