In 2014, the entire United States was focused on the developing Flint Water Crisis. Residents came forward in droves complaining about health problems and dirty-looking water, and a team of experts including the pediatrician and 2022 Bernard Lown Award winner Dr. Mona Hanna-Attisha released findings that the entire town was being exposed to lead through their water service lines. Years later, the EPA’s website (last updated in March of 2023) is still recommending residents take precautions like using water filters.
This debacle pushed Michigan’s legislature to revise its Lead and Copper Rule to 1) require water utilities to conduct inventory of existing water service lines in the next two years and 2) replace all the identified lead-containing lines by 2041. Michigan is the first state to require this proactive replacement and will be using funding from the Bipartisan Infrastructure Law of 2021 to complete the replacements.
There is no safe level of lead exposure, especially for young children. Lead exposure is known to impact neurodevelopment, translating to negative health impacts like mental illness and increased mortality down the line. Water through lead service lines is the primary source of exposure for children; it follows that replacing old lead service lines would be an effective preventative measure. But to what degree exactly? Let’s take a look.
The Breakdown
Dr. Hanna-Attisha and colleagues recently co-authored a cost-benefit analysis in Health Affairs, attempting to nail down the quantitative benefits of replacing lead service lines according to the revised Michigan Lead and Copper Rule.
The analysis estimates 423,479 lead service lines in Michigan that should be replaced. Over a forty-year period (2020-2060), predicted benefits based on 5% per year replacement rate over the next twenty years are:
- A reduction in lead exposure for 420,800 newborns
- 86% of which live in a household 250% below FPL
- 36% of which are non-white
- A net societal program benefit of $1.91 billion
- $130 million in health cost benefits
- $43 million in education cost benefits
- $602.9 million in total benefits to Black households, which have been historically been disproportionately exposed to lead
- A societal return on investment of $2.44 per dollar invested
The estimated break-even year when societal benefits first exceed cost is 2038, meaning the break-even year would come 2 years before the project was even completed.
The authors note several limitations with their cost-benefit analysis. Lead exposure has numerous impacts on human health, such as its impact on aggression and violence, and this article was unable to capture the full scope of those health effects. This resulted in a conservative estimate of the total societal benefits of lead service line replacement, as not all the potential improvements could be captured in statistically significant ways.
The state has four potential plans it could take to replace the lines on both a 10- and 20-year timeline. This analysis found that the expedited replacement timeline has the potential to benefit an additional 68,700 children and increase the estimated total net societal program benefits to $2.48 billion, up from $1.91 billion.
Implications of these findings
Preventative care is often overlooked and devalued as not profitable, but this cost-benefit analysis calls that assumption into question.
This data suggests that an effective way to follow through would be to invest in widespread, community-based preventative care. Rather than treating individual patients after lead exposure damage is done, it would be far more efficient and cost-effective to simply remove that exposure in the first place.
Hospitals often include health equity as one of their core missions. Factors like income and insurance status are closely linked with health and can be difficult for hospitals to address. These findings suggest hospitals could make a significant positive societal impact by applying their community investment funds to public health interventions like de-leading water lines.
“By taking on a life in medicine, we have places ourselves on the front lines of some of the most important battlegrounds of society…sometimes that means being on guard for a city that’s being poisoned.”
-Dr. Mona Hanna-Attisha receiving the 2022 Bernard Lown Award for Social Responsibility
While this study only looked at Michigan, other states should take note. The country as a whole has a $14.2 billion “Fair Share” deficit, meaning most nonprofit hospitals spent less on charity care and community investment than the value of their tax breaks. What if we applied even a portion of those funds toward tangible, effective public health interventions?
The research is certainly promising. A 1987 EPA cost-benefit analysis estimated the benefits to outweigh the costs by about 4 to 1. The Environmental Defense Fund estimates that lead service line replacement could prevent up to 6,150 deaths from cardiovascular disease alone and deliver societal benefits of up to $51 billion across the country.
To be a strong, productive nation, we need to be healthy. Perhaps our best return on investment would be prioritizing preventative care, rather than attempting to whack-a-mole problems as they come up.