NOTE: This is Part One of a two-part Special TrustDALE Investigation. Part one focuses on the crisis currently facing the U.S. Look out for Part Two in which we will take a more in-depth look at some possible solutions for the indoor air quality crisis and what, if anything, is being done now.

Americans have recognized the importance of regulating air quality for over a half-century. Beginning in the 1950s, Congress passed increasingly powerful legislation to regulate air pollution and air quality. These regulations culminated in the Clean Air Act of 1970 and the establishment of the Environmental Protection Agency (EPA) that same year. One of the first tasks of the newly formed EPA was to monitor and enforce the provisions of the Clean Air Act. Over the last half-century, new legislation and increased enforcement have dramatically lowered the levels of pollutants in the air Americans breath. However, America still faces an acute air quality crisis.

Despite the successful efforts of the public and private sectors to reduce air pollution, millions of Americans are still suffering every day from levels of pollution well beyond the standards accepted by the EPA and other regulators. The crisis is not with the air that hangs over our cities, but with the air inside our homes, schools, and offices. The EPA itself has determined that the average American spends 90% of their time indoors.1 And yet to date, there is almost no regulation of indoor air quality. This means that all of the work done by the EPA and the private sector over more than 50 years has only increased the air quality for approximately 144 minutes of each day. For the other nearly thirteen hundred minutes a day, Americans are breathing completely unregulated air that contains pollutants at 2 to 5 times the outdoor levels.2

Simply put, America is facing an indoor air quality crisis that is out of control.

The Cost of Indoor Air Pollution

Fighting indoor air pollution is not an inconsequential battle. In fact, the effects of poor indoor air quality can be measured in dollars. According to the most recent government data:3

"U.S. health care spending grew 3.9 percent in 2017, reaching $3.5 trillion or $10,739 per person.  As a share of the nation's Gross Domestic Product, health spending accounted for 17.9 percent."

Rich Johnson, founder of Air Allergen and Mold Testing, has been working to bring that number down. According to Johnson, improving indoor air quality could result in some huge savings. “I started out thinking it would be about $6 billion, and then I thought maybe $50 billion, and then maybe $100 billion, and I'm up to about $200 billion.” Johnson estimates that $200 billion or more could be cut out of America’s healthcare costs by reducing a wide range of diseases that are caused or exacerbated by bad indoor air. “Not only asthma but COPD,...cardiovascular disease, strokes, heart attacks, kidney failure. There's some [research] that links [air quality] with diabetes...There's a threshold above which your immune system will not be able to take care of you. All we have to do is to bring it down below the threshold of that immune system and you're not going to have to have emergency interventions.”

It’s clear that in dollars and cents, the cost of America’s indoor air quality crisis is formidable. As Congress struggles to reduce the cost of healthcare, indoor air quality has to be part of the discussion. Each day, the average American eats 4 pounds of food but breathes nearly 40 pounds of air. The regulatory structures in place to keep food safe are vast and far-reaching. But there are currently no federal standards for indoor air quality, much less any regulation to curtail indoor air pollution.

Indoor Air Pollution and Income Inequality

Indoor air pollution is first and foremost a health issue. But as with many health issues in the U.S., indoor air pollution is also a significant contributor to income inequality. It also perpetuates generational poverty. Johnson points out that when he began working with air quality testing in Atlanta, “a lot of these places were on the southside of Atlanta,” an area disproportionately affected by poverty. It became increasingly clear that indoor air quality was a contributing factor to the cycle of poverty in these neighborhoods. As Johnson puts it, poor indoor air quality “was affecting homes where children were living, adversely affecting them. And [when] these children [don’t] feel well, they go to school, and they don't do well. [And when] they get out, they don't get the good jobs. And then they have to raise their [families] in substandard housing.”

Johnson’s ideas about the impact of poor indoor air quality on generational poverty were more than a hunch. Thomasville Heights Elementary School is one of the lowest performing schools in the state of Georgia, as well as one of its poorest. Many students live in Section 8 subsidized housing right near the school. And a significant factor in the school’s low performance was a 40% student turnover rate annually, largely due to housing instability.

But all that changed when the Atlanta Volunteer Lawyers Foundation (AVLF) began working with the school and the local community. They helped tenants address outstanding housing issues so they could stay in their homes. One major complaint was indoor air quality. Johnson and Air Allergen “started doing all of the [indoor air quality] inspections for the AVLF, and [they] provided the expert testimony for them in the courts.”

What followed was a dramatic decrease in student turnover. Annual turnover dropped from 40% to 25%. Simply addressing housing concerns, including unaddressed indoor air quality issues, was giving these children a better chance at academic success.

Resistance to Indoor Air Quality Regulations

The question that plagued Johnson—and which he has been trying to solve—is why indoor air quality has received such little attention. For a problem that costs so much in money and human lives, the level of interest from the private and public sectors is surprisingly low. What Johnson found was that the lack of interest was actually the result of willful ignorance. It turns out that many of the stakeholders who would be involved in increasing indoor air quality have competing interests that lead them away from indoor air quality.

To start, the medical establishment, which would be the obvious candidate for addressing this health crisis, was uninterested. At all levels of medicine, it was more profitable not to address indoor air quality. Johnson laid out his findings as follows:4

  • Drug Companies sell pharmaceuticals
  • Allergists treat allergies
  • Environmentalists focus on outdoor air
  • Pharmacists dispense drugs
  • Pulmonologists repair the lungs
  • Emergency room doctors stabilize the patient
  • Insurance Companies, Medicaid, and Medicare pay for healthcare, not prevention of health care costs
  • Health departments focus on treatment
  • Politicians are influenced by many stakeholders

When it comes down to it, most stakeholders in the medical industry had little to gain from addressing the root cause of so many illnesses.

Reducing Healthcare Costs by Increasing Indoor Air Quality

Much of the discussion around reducing the cost of healthcare in the U.S. has centered on improving preventive care. The theory is that more visits to primary care physicians, better screening for a variety of diseases, and other preventive visits to the doctor will reduce healthcare costs. Unfortunately, research seems to indicate that preventive medicine is not a huge money-saver.5 So why is it getting all the press? One possibility is because preventive medicine is still a money-maker for the medical industry. Meanwhile, preventing medical visits in the first place gets very little attention.

According to the largest U.S. study of air pollution and respiratory emergency room visits of patients of all ages,6 a strong association was found between fine particulate pollution in the air and increased ER visits, especially by children. Specifically:

"An association was found between fine particulate pollution (PM2.5) and respiratory ER visits among children and adults under the age of 65, with the strongest association among children. Per 10 microgram per cubic meter (μg/m3) increase in PM2.5, the rate of an ER visit increased 2.4 percent in children and 0.8 percent among adults under 65."7

Yet even this study was deeply flawed in that it only focused on outdoor air pollution levels. However, it can easily be extrapolated that fine particulate pollution in indoor air is also a leading factor in ER visits.

If we could increase the quality of indoor air altogether, it would almost certainly reduce visits to the ER specifically and healthcare spending in general.

NOTE: This is Part One of a two-part Special TrustDALE Investigation. Part One focuses on the crisis currently facing the U.S. Look out for Part Two in which we will take a more in-depth look at some possible solutions for the indoor air quality crisis and what, if anything, is being done now.


1. U.S. Environmental Protection Agency. (1989). Report to Congress on indoor air quality: Volume 2. EPA/400/1-89/001C. Washington, DC.

2. U.S. Environmental Protection Agency. (1987). The total exposure assessment methodology (TEAM) study: Summary and analysis. EPA/600/6-87/002a. Washington, DC.

3. Historical - Centers for Medicare & Medicaid Services. (2018, December 11). Retrieved from

4. Johnson, Richard. (2019). Position Paper.

5. Carroll, A. E. (2018, January 29). Preventive Care Saves Money? Sorry, It's Too Good to Be True. Retrieved from

6. Heather M Strosnider, Howard H Chang, Lyndsey A Darrow, Yang Liu, Ambarish Vaidyanathan, Matthew J Strickland. Age-Specific Associations of Ozone and PM2.5 with Respiratory Emergency Department Visits in the US. American Journal of Respiratory and Critical Care Medicine, 2018; DOI: 10.1164/rccm.201806-1147OC

7. Air pollution increases ER visits for breathing problems. (2019, January 18). Retrieved from

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