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Promising Practices
Issue Brief

Lead Screening for Children Enrolled in Medicaid: State Approaches
By Carrie Farmer

Long-Term Effects of Lead Poisoning

Sources of Lead

Certain Groups Are High Risk

Treatments for Lead Poisoning

Screening Children for Lead Poisoning

Screening is Mandatory for Children Enrolled in Medicaid

State Practices

What Can States Do to Increase Screening Rates

Conclusion

Appendix A. National Survey of Lead Screening Programs and Practices

Appendix B.

Appendix C. Resources

Notes

References

Acknowledgments

Each year, thousands of children are affected by lead poisoning. According to the Centers for Disease Control and Prevention (CDC), between 1991 and 1994, 4.4 percent¹ of children between the ages 1 and 6 had blood lead levels (BLLs) high enough to be considered dangerous. In fall 2000, the Forum for State Health Policy Leadership at the National Conference of State Legislatures (NCSL) conducted a national survey on state policies and practices for screening Medicaid-enrolled children for lead poisoning. (Appendix A contains the survey method.) This paper describes the seriousness of the issue, the difficulties involved in implementing screening programs, and results from the survey about state approaches to improving their screening practices.

Long-Term Effects of Lead Poisoning

Children with low levels of lead poisoning are not likely to look or act sick in any way that is noticeable to a parent or even to a doctor. However, elevated blood lead levels are associated with developmental delays, learning disabilities and behavioral problems, including attention deficit disorder² and juvenile delinquency. ³ There is also a strong correlation between mental ability and lead levels: for every 10m g/dL increase in blood lead levels, a child's IQ is lowered by four to seven points.⁴ In pregnant women, elevated lead levels can cause low birth weight⁵ or miscarriage. ⁶ High levels of lead poisoning can cause seizures, coma, severe brain and kidney damage and death.

Young children under age 6 are more susceptible to lead poisoning than are older children or adults. There are several reasons for this.

• Children's small bodies absorb lead at a much higher rate relative to their body weight than adults' bodies do.
• Their developing brains have not yet completely formed the crucial blood-brain barrier, the "selective gate" that helps block toxins from the brain in adults, so lead can pass directly from the bloodstream into the brain.
• Children have a higher prevalence of iron deficiency, which causes increased absorption of lead.⁷
• They are more likely to play in areas where they can be exposed to lead and are more likely to put contaminated hands and fingers into their mouths.

Sadly, the effects of lead poisoning are irreversible.

Sources of Lead

Lead-based paint is the number one source of lead poisoning today. Found in most homes built before 1950-and in many built before 1978-this paint wears down into flakes, chips and dust as it ages or if it is not properly maintained. In addition, renovation or maintenance projects that disturb lead-based paint can create a lead dust hazard. The dust is especially treacherous because it can be found almost anywhere-on toys, walls, floors, tables, carpets or fingers. Because young children are apt to put almost anything they come across into their mouths, they quickly ingest the lead-contaminated dust. Dust that is in the air can be inhaled, and the absorption rate of lead that enters the body through the lungs is close to 100 percent. Some very young children may chew or suck on paint that is found on accessible surfaces such as windowsills, banisters and steps. Sometimes children will eat paint that is chipping or peeling because it tastes sweet or because they have pica (a condition characterized by eating non-food items). Outside the house, lead paint chips or dust can settle into the soil. When children play in the dirt (and often eat it), they are again exposed.

In addition, lead can be found in aging water pipes, non-glossy vinyl window blinds made before 1996, some lead-soldered canned foods imported from other countries, and some playground equipment painted before 1978. Parents whose occupation involves working with or around lead (car repair, industry machinery, bridge construction, etc.) can unknowingly bring lead dust or scraps from their jobs to the house. Certain ethnic, traditional or home remedies also involve lead ingestion. For example, some Latino cultures-unaware of the risks of lead poisoning-use the powders Azarcon and Greta, both almost 100 percent lead, to relieve diarrhea.

Certain Groups Are High Risk

Low-income and minority-especially African-American and Mexican-American-children are much more at risk for lead poisoning than are children in middle or high-income families or white children. The CDC's 1991-1994 National Health and Nutrition Examination Survey (NHANES) found that 8 percent of low-income children have lead poisoning, compared to 1 percent to 2 percent of middle or high-income children. More than 11 percent of African-American children and 4 percent of Mexican-American children have lead poisoning, compared to 2.3 percent of white children.

The General Accounting Office (GAO) found that the prevalence of lead poisoning in children who are enrolled in Medicaid is nearly five times that of non-Medicaid children. In fact, 60 percent of all children with lead poisoning (with BLLs greater than 10m g/dL) are enrolled in Medicaid, and 83 percent of all children with BLLs greater than 20m g/dL are enrolled in Medicaid.⁸

Treatments for Lead Poisoning

The treatment for children with lead poisoning who have BLLs between 10m g/dL and 45m g/dL is usually environmental abatement to eliminate or control the source of lead in the child's environment. For children with BLLs greater than 45m g/dL, the recommended treatment is chelation therapy, a procedure that flushes excess lead from the body. Chelation uses drugs, given either orally or intravenously, to "grab onto" lead particles in the blood and then excrete them. Environmental abatement is a necessary part of the treatment to prevent additional lead from entering the body.

Health Care Financing Administration (HCFA) policy requires state Medicaid programs to pay for an environmental inspection of a Medicaid child's home upon notification of lead poisoning. A 1999 GAO report found that states had interpreted previous HCFA policy to make this coverage optional;⁹ as a result, HCFA clarified the requirement in 1999. NCSL's survey on state lead screening programs and policies found that 22 state Medicaid programs now cover environmental inspection (Table 1).

Table 1.
Medicaid Coverage of Case Management, Environmental Assessment or Abatement
(Applicable fields are shaded; Inapplicable fields denoted with "=")

* N/R = No Response

1 In some states, coverage of case-management is limited-for example, coverage applies only under specific circumstances and only within Medicaid managed care.

Environmental inspections serve only to determine the source of the lead poisoning; however, the financial burden for controlling or removing the source falls to the parents or the property owner, depending on state and local laws. Rhode Island is the only state where the Medicaid program covers a type of abatement. Through a Section 1115 waiver, the state will pay for window replacement in homes of lead-poisoned children.

Controlling children's exposure to lead can be difficult. Complete removal of lead paint from a house is usually impractical because it can be very expensive and carries with it the risk of increased lead exposure from dust if the removal is not done correctly. Certified experts are available to undertake lead hazard evaluation and control activities in most states, providing services including risk assessments, abatement and other less intensive interventions. In most cases, the best way to prevent lead poisoning is to ensure that properties are maintained so that lead-based paint is intact and to use lead-safe work practices for repairs and renovation to prevent the creation of lead dust hazards. In addition, parents must be extremely vigilant about cleaning areas of the house where there is lead paint or dust. Appendix B contains the Environmental Protection Agency's (EPA) recommendations for reducing childhood exposure to lead.

Screening Children for Lead Poisoning

A vital step in preventing the tragedy of lead poisoning is testing or screening children for elevated BLLs. Screening is a relatively simple procedure that can be conducted in a physician's office, public health clinic or other primary care site. It typically requires that a blood sample be collected from a child through venipuncture (inserting a needle into a vein and collecting a vial of blood). The blood then is analyzed by a laboratory. A capillary (fingerstick) blood sample also may be used, but as the procedure occasionally results in a false positive; any elevated BLL found through this method usually is double-checked by the venipuncture method. The U.S. Food and Drug Administration (FDA) recently approved a hand-held blood lead testing device that can provide results immediately; to use this device, however, physicians' offices or public health clinics must be certified by the FDA's Clinical Laboratory Improvement Amendments (CLIA). ¹⁰

The CDC recommends that states develop statewide screening plans for their jurisdictions based on an analysis of risk data, preferably state or local data and an inclusive planning process. The CDC provided a sample targeted screening recommendation for use as an interim measure until a state plan is developed, which calls for screening of children at ages 1 and 2, as well as children between the ages of 36 months and 72 months who have not been previously screened, if they meet one of the following criteria:¹¹

• The child resides in a zip code where greater than 27 percent of housing was built before 1950;
• The child receives services from public assistance programs for the poor, such as Medicaid or the Supplemental Food Program for Women, Infants, and Children (WIC); or
• The child's parent or guardian answers "yes" or "I don't know" to any of the following three questions:

1. Does your child live in or regularly visit a house that was built before 1950?
2. Does your child live in or regularly visit a house built before 1978 with recent or ongoing renovations or remodeling (within the last six months)?
3. Does your child have a sibling or playmate who has or did have lead poisoning?

In the absence of screening recommendations from the health department, the CDC recommends that universal screening (i.e., of all young children) be done.

Screening is mandatory for children enrolled in Medicaid

Current federal law requires that all children enrolled in Medicaid be screened for lead at age 12 months and 24 months (or through 72 months if the child has not been previously screened) as part of Medicaid's early and periodic screening, diagnosis and treatment (EPSDT) requirement.

However, as a recent GAO report highlighted, this requirement often is not met. In fact, the GAO's analysis of Medicaid billing data from 1994 to 1995 showed that only 18 percent of all Medicaid children received a lead toxicity screening.¹² The GAO's analysis of national data from NHANES 1991-1994 showed similar rates, estimating that only 19 percent of Medicaid children had been screened. The GAO report, published in January 1999, found several possible explanations for this, including the following.

• Federal and state agencies do not monitor or ensure the implementation of federal screening policies. The report found that HCFA did not regularly audit state Medicaid programs for compliance with EPSDT lead screening policies and that state Medicaid programs likewise did not monitor screening by providers to determine whether children were being screened. In addition, the report faulted the Health Resources and Services Administration (HRSA) for not identifying federal health centers that do not follow screening guidelines.
• The perception of the problem's seriousness varies from place to place. The report found that physicians often perceive that there is not a lead poisoning problem in their communities and therefore do not believe that screening is worth the costs associated with it.
• There are general difficulties in providing preventive care to the Medicaid population. It is difficult for health officials to convince parents that preventive care is important when their children are not sick, especially when these parents have many competing priorities. Laboratory tests such as lead screening often require an additional trip, separate from the provider visit, which is difficult because many parents of Medicaid-enrolled children lack transportation and child care and have difficulty in taking time off work. In addition, these parents may not understand the importance of the tests.¹³

There has been federal response to the GAO report. HCFA has tightened its reporting requirements (Form HCFA-416) to ensure that screenings are being administered. Now, each state must report the number of screening blood lead tests that are given each year. April 2000 was the deadline for the first round of collection of this data; HCFA officials expect return rates to improve in 2001 as states devise mechanisms and data systems to collect and manage this information. Data from the 2000 forms will be distributed in HCFA's annual report, due to be published in winter 2001.

In October 1999, HCFA also sent out a "Dear State Medicaid Director" letter, which outlined the findings of the GAO report and described the department's initiatives to increase the rate of screening in Medicaid children. This letter also reminded state Medicaid directors of HCFA's screening requirements and reiterated the importance of screening this population. HCFA is working with the CDC and with the Health Resources and Services Administration (HRSA) on additional initiatives. They also have contracted with the Alliance to End Childhood Lead Poisoning to develop state and provider education programs.

State Practices

Results from NCSL's survey show that individual states identify barriers to screening consistent with the ones described in the GAO report: provider noncompliance, lack of access to laboratories, lack of funding, transient population, and problems with parental follow-through. Of the 44 states that responded, almost every state highlighted provider noncompliance as the most significant barrier. Twenty-one states reported that providers felt that "lead poisoning isn't a problem in their state" and 14 states reported that providers were not aware of the risks for lead poisoning nor of the federal screening requirements. Nine states reported that the method of screening (capillary or venipuncture) was a significant barrier because it was difficult, required training and was time-intensive. (Table 2 contains complete results).

Table 2.
Barriers to Screening Children Enrolled in Medicaid
(Applicable fields are shaded; Inapplicable fields denoted with "=")

¹ Many laboratories are off-site, requiring parents to travel to have their children tested. Alaska has extremely remote villages. Louisiana does not have enough EPSDT providers.

² Other barriers include lack of cultural sensitivity and low reimbursement rates for the test.

Most states (37) report that blood lead screening of Medicaid children happens regularly as a part of EPSDT visits at ages 12 months and 24 months. In three states-Massachusetts, New Jersey and Rhode Island-state law mandates screening of all children younger than age 6, regardless of Medicaid status. Three states reported that screening was left to the discretion of the provider and was not required by the state (table 3).

Medicaid agencies or state departments of health are responsible for ensuring that Medicaid children are screened in many states (23). Eight states either contract with a third party or use some other means of ensuring compliance. In 18 states, however, no agency or other entity has direct responsibility for this, though six states are in the process of developing compliance plans (table 4).

Table 3.
When Screening of Medicaid-Enrolled Children Occurs
(Applicable fields are shaded; Inapplicable fields denoted with "=")

¹ Required by state, in compliance with HCFA requirements.

² Required for all children regardless of Medicaid status.

³ Other sites include county and public health departments, federal and state health clinics and HeadStart classes.

Table 4.
Who Ensures that Providers Are Complying with Screening Regulations?
(Applicable fields are shaded; Inapplicable fields denoted with "=")