Medicaid and CHIP Policy Options
Covering over 35% of children in the United States, Medicaid can provide access to critical diagnostic services for children under the age of 21. Medicaid can be used to improve lead exposure prevention and response strategies, like lead abatement and blood lead level screening requirements, and subsequent treatment. Similarly, Medicaid provides diagnosis and treatment for asthma and related conditions, which creates opportunities to provide preventive care and proactive screening for home hazards. Medicaid can be a tool for state legislatures looking to improve population health in part because of the large number of children covered by Medicaid and because of the opportunity for federal matching of state funds, as the federal government provides a minimum of 50% towards Medicaid services.
Paying for Screening and Treatment
The Early, Periodic, Screening, Diagnostic and Treatment (EPSDT) benefit in the Medicaid program provides comprehensive health services to children by covering all screening and treatment services that are deemed medically necessary. The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for oversight of the Medicaid program, requires screening tests at ages 1 and 2 in alignment with the Bright Futures Guidelines recommendations. State Medicaid programs are required to cover diagnosis and treatment for asthma. In addition, CMS requires children between the ages of 2 and 6 with no record of a blood lead screening test to be screened for lead.
Because EPSDT is a comprehensive benefit, all services that are medically necessary for treatment of increased blood lead levels and asthma care are covered by Medicaid, even if those services are not otherwise covered under a state’s Medicaid program. To connect children with needed treatment services, states can use case management services to refer children to treatment and coordinate services. Case managers can help provide education regarding lead hazards, cleaning techniques and supplies. Medicaid can pay for on-site home assessments conducted by certified lead risk assessors to identify potential lead exposure sources. Maryland recently enacted legislation to reduce the blood lead level threshold necessary to refer a child for case management services.
Lead exposure and prevalence are often concentrated in areas of a state, such as areas that are primarily low-income or disproportionately people of color. State policymakers may consider a targeted testing approach to improve screening in high-risk areas and populations. CMS allows states to develop targeted plans to ensure children who are at higher risk are tested. Arizona is currently the only state with a targeted approach approved by CMS. Using data from the health department, Arizona developed a ZIP code risk index and tests all children living in high-risk zip codes in accordance with EPSDT requirements. Universal screening policies are more protective because lead-based paint can be present in any home built before 1978 and there are other sources of lead exposure such as imported pottery, medicines, and dust brought home from work settings.
Other Medicaid Options
Section 1115 waivers provide another opportunity for states to provide coverage of lead abatement and screening activities. Section 1115 waivers allow states to waive certain Medicaid requirements in order to design experimental or demonstration programs to meet their state’s needs. For example, Michigan used an 1115 waiver to respond to the Flint water crisis starting in 2015. Michigan’s 1115 waiver has since been amended to include resources for lead abatement from all sources in the home, not just water pipes.
These 1115 waivers can also be used to address other housing health hazards such as asthma triggers, which can include pests, tobacco smoke and mold. People with low incomes are disproportionately affected by asthma and most low-income children with asthma are enrolled in Medicaid or the Children’s Health Insurance Program. Massachusetts uses an 1115 waiver to provide prevention services not typically covered by Medicaid including home visits, care coordination and case management, supplies to reduce environmental triggers (such as high-efficiency vacuums and air filters, and mite-proof mattress covers), and pest management supplies and services. Missouri’s Medicaid program allows for one hour of asthma education and two asthma environmental assessments per year. Oregon uses the targeted case management Medicaid benefit to provide these services to children with asthma.
Services provided through Medicaid to help better manage asthma can potentially lead to cost savings for states. For example, Rhode Island’s Home Asthma Response Program (HARP) found a 75% reduction in asthma-related hospital visits for individuals participating in the program, which included asthma education and supplies to reduce triggers.
Health Services Initiatives
Access to funding for actual removal and abatement of housing hazards is often a barrier for states in achieving healthy housing goals. CHIP allows states to use CHIP funding to implement health services initiatives (HSIs) for improving the health of low-income children (§ 2105(a)(1)(D)(ii) of the Social Security Act). States receive annual allotments, similar to a block grant, to fund their CHIP programs. The allotment includes funding for administration: A state may use up to 10% of its total CHIP funding to cover administration costs for the program. For any funding remaining within that 10% cap, a state can choose to apply it to an HSI. In addition, CHIP receives an enhanced federal matching rate compared to Medicaid, with the minimum 65% federal contribution. An HSI can provide a funding source to remove hazards from homes.
States have the option to choose the type and scope of HSIs. As of 2019, according to the Medicaid and CHIP Payment and Access Commission (MACPAC), 24 states had 71 HSIs approved for a variety of activities, including six states approved for programs to promote lead screening, treatment and abatement, and one state using an HSI to address asthma triggers. Lead abatement programs can include educating families about lead exposure, testing, and case management services.
Indiana has an HSI which supports targeted lead abatement activities to mitigate all lead risks; services can be rendered to the home and surrounding property. Missouri’s HSI provides support to local public health agencies’ efforts to monitor and manage children up to age 6 with elevated blood-lead levels. Michigan’s and Ohio’s HSIs address lead abatement through removal and replacement of lead-painted components such as doors, windows, and floors, stabilizing paint, and soil replacement or covering. The installation of water filters and relocation per diems for families is also covered. Ohio’s HSI further provides funding to support the housing registry for lead levels in rental properties.
HSIs can have many facets. For example, Maryland has a multi-part initiative, which expands identification and abatement programs for children in low-income families and provides environmental assessments and education to families regarding lead hazards and asthma triggers. The HSI is targeted to nine counties for community health workers to provide education support and outreach for children with lead poisoning and asthma.