[Senate Hearing 107-984]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 107-984


                      LEAD-BASED PAINT POISONING:
                           FEDERAL RESPONSES

=======================================================================

                                HEARING

                               before the

               SUBCOMMITTEE ON HOUSING AND TRANSPORTATION

                                 of the

                              COMMITTEE ON
                   BANKING,HOUSING,AND URBAN AFFAIRS
                          UNITED STATES SENATE

                      ONE HUNDRED SEVENTH CONGRESS

                             SECOND SESSION

                                   ON

  AN OVERVIEW OF WHAT FIVE FEDERAL AGENCIES--HUD, EPA, DOJ, CMS, AND 
  CDC--ARE CURRENTLY DOING TO HELP MAKE HOUSING LEAD-SAFE FOR CHILDREN

                               __________

                              JUNE 5, 2002

                               __________

  Printed for the use of the Committee on Banking, Housing, and Urban 
                                Affairs



89-475              U.S. GOVERNMENT PRINTING OFFICE
                            WASHINGTON : 2003
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            COMMITTEE ON BANKING, HOUSING, AND URBAN AFFAIRS

                  PAUL S. SARBANES, Maryland, Chairman

CHRISTOPHER J. DODD, Connecticut     PHIL GRAMM, Texas
TIM JOHNSON, South Dakota            RICHARD C. SHELBY, Alabama
JACK REED, Rhode Island              ROBERT F. BENNETT, Utah
CHARLES E. SCHUMER, New York         WAYNE ALLARD, Colorado
EVAN BAYH, Indiana                   MICHAEL B. ENZI, Wyoming
ZELL MILLER, Georgia                 CHUCK HAGEL, Nebraska
THOMAS R. CARPER, Delaware           RICK SANTORUM, Pennsylvania
DEBBIE STABENOW, Michigan            JIM BUNNING, Kentucky
JON S. CORZINE, New Jersey           MIKE CRAPO, Idaho
DANIEL K. AKAKA, Hawaii              JOHN ENSIGN, Nevada

           Steven B. Harris, Staff Director and Chief Counsel

             Wayne A. Abernathy, Republican Staff Director

                    Jennifer Fogel-Bublick, Counsel

                  Jonathan Miller, Professional Staff

           Sherry E. Little, Republican Legislation Assistant

                 Mark A. Calabria, Republican Economist

   Joseph R. Kolinski, Chief Clerk and Computer Systems Administrator

                       George E. Whittle, Editor

                   Frank E. Wright, Assistant Editor

                                 ______

               Subcommittee on Housing and Transportation

                   JACK REED, Rhode Island, Chairman

                 WAYNE ALLARD, Colorado, Ranking Member

THOMAS R. CARPER, Delaware           RICK SANTORUM, Pennsylvania
DEBBIE STABENOW, Michigan            JOHN ENSIGN, Nevada
JON S. CORZINE, New Jersey           RICHARD C. SHELBY, Alabama
CHRISTOPHER J. DODD, Connecticut     MICHAEL B. ENZI, Wyoming
CHARLES E. SCHUMER, New York         CHUCK HAGEL, Nebraska
DANIEL K. AKAKA, Hawaii

                     Kara M. Stein, Staff Director

              Tewana Wilkerson, Republican Staff Director

                                  (ii)
?

                            C O N T E N T S

                              ----------                              

                        WEDNESDAY, JUNE 5, 2002

                                                                   Page

Opening statement of Senator Reed................................     1
    Prepared statement...........................................    28

Opening statements, comments, or prepared statements of:
    Senator Allard...............................................     2
        Prepared statement.......................................    29
    Senator Corzine..............................................    14
        Prepared statement.......................................    30
    Senator Stabenow.............................................    30

                               WITNESSES

David E. Jacobs, Ph.D., Director, Office of Healthy Homes and 
  Lead Hazard Control, U.S. Department of Housing and Urban 
  Development....................................................     3
    Prepared statement...........................................    31
    Response to written questions of:
        Senator Reed.............................................    46
        Senator Carper...........................................    49
Thomas L. Sansonetti, Assistant Attorney General, Environment and 
  Natural Resources Division, U.S. Department of Justice.........     6
    Prepared statement...........................................    34
    Response to written questions of:
        Senator Reed.............................................    51
        Senator Carper...........................................    53
Adam Sharp, Associate Assistant Administrator, Office of 
  Prevention, Pesticides, and Toxic Substances, U.S. 
  Environmental Protection Agency................................     8
    Prepared statement...........................................    38
    Response to written questions of Senator Reed................    53
Ruben King-Shaw, Jr., Deputy Administrator and Chief Operating 
  Officer, Centers for Medicare and Medicaid Services............    10
    Prepared statement...........................................    40
    Response to written questions of:
        Senator Reed.............................................    67
        Senator Carper...........................................    74
Richard J. Jackson, M.D., M.P.H., Director, National Center for 
  Environmental Health, Centers for Disease Control and 
  Prevention, U.S. Department of Health and Human Services.......    12
    Prepared statement...........................................    42
    Response to written questions of Senator Reed................    74

                                 (iii)

 
                      LEAD-BASED PAINT POISONING:
                           FEDERAL RESPONSES

                              ----------                              


                        WEDNESDAY, JUNE 5, 2002

                               U.S. Senate,
  Committee on Banking, Housing, and Urban Affairs,
                Subcommittee on Housing and Transportation,
                                                    Washington, DC.

    The Subcommittee met at 2:45 p.m. in room SD-538 of the 
Dirksen Senate Office Building, Senator Jack Reed (Chairman of 
the Subcommittee) presiding.

             OPENING STATEMENT OF SENATOR JACK REED

    Senator Reed. The hearing will come to order.
    Good afternoon. Let me welcome everyone to today's hearing 
on Federal responses to lead-based paint poisoning. I hope to 
bring greater attention to this terrible problem in our 
Nation's housing and its effects particularly on children. It 
is a follow-up to the Senate Housing Subcommittee hearing held 
last year regarding State and local responses to lead-based 
paint poisoning.
    Over a decade ago, the U.S. Department of Health and Human 
Services announced a strategic plan for the elimination of 
childhood lead poisoning because it recognized the detrimental, 
long-lasting effects on children from exposure to lead. The 
efforts to achieve this long-established goal of eliminating 
lead poisoning by the year 2010 has stalled and may, in fact, 
be moving in the opposite direction.
    Not only are Federal laws not being enforced, such as the 
requirement that all Medicaid eligible children be screened for 
lead, but it also appears that there is currently no 
coordinated action to eliminate childhood lead poisoning.
    The previous Administration created a Task Force on 
Children's Environmental Health and Safety Risks. This task 
force was 
cochaired by the Secretary of the U.S. Department of Health 
and Human Services and the Administrator of the Evironmental 
Protection Agency, and developed a set of recommendations to 
eliminate childhood lead poisoning in the United States as a 
major public health problem by the year 2010.
    Specifically, this comprehensive Government-wide strategy 
called for making 2.3 million homes where children under the 
age of 6 live lead-safe by controlling lead-paint hazards. It also 
called for public education programs, strict enforcement of lead-paint 
regulations, as well as encouraging early interventions for at-
risk children.
    With only 8 years to go until we are to have eliminated 
childhood lead poisoning, it is estimated that nearly one 
million preschool children living in the United States continue 
to have blood-lead levels high enough to impair their ability 
to think, concentrate, and learn.
    Unfortunately, except for the most severely poisoned 
children, there is no medical treatment for this disease. And 
even then, treatment may only reduce the level of lead present 
in the body, not reverse the harm already caused. The only 
effective treatment is preventing exposure, which occurs as a 
result of deteriorating paint in our Nation's housing stock.
    The Department of Housing and Urban Development estimated 
in its latest national survey that lead still remains in about 
39 million dwelling units, or 40 percent of all U.S. housing.
    Federal efforts to reduce the hazards of lead-based paint 
poisoning began 31 years ago, with the enactment of the Lead-
Based Paint Poisoning Prevention Act. This Act required the 
Secretary of HUD to establish and implement procedures to 
eliminate lead hazards from public housing.
    In 1992, Title X of the Housing and Community Development 
Act authorized major changes in Federal law on the control of 
lead-based paint hazards and the reduction of lead exposure. 
Title X defined hazard in such a way that it included 
deteriorating lead-paint, and the lead-contaminated dust and 
soil that the lead-paint generates. It also mandated the 
creation of an infrastructure that would help correct lead-
paint hazards in all of our Nation's housing. In particular, 
Title X required coordinated action between 
several Federal agencies regarding lead poisoning, including 
the Department of Housing and Urban Development, the 
Environmental Protection Agency, and the Centers for Disease 
Control and Prevention.
    While we have made progress in dramatically reducing the 
number of children with elevated blood levels, significant 
barriers and obstacles to the elimination of this environmental 
health hazard remain. It raises significant questions which we 
will address in this hearing, significant questions that need 
to be addressed. Specifically: Why are we still only evaluating 
20 percent of Medicaid eligible children, and why we are not 
coordinating better?
    I would hope as we go forward with this hearing to develop 
all of these issues. We are fortunate to have a distinguished 
panel. But before I introduce the panel, let me introduce my 
colleague, the Ranking Member, Senator Allard.

                COMMENTS OF SENATOR WAYNE ALLARD

    Senator Allard. Mr. Chairman, I have a short statement of 
only about 30 pages.
    [Laughter.]
    I have one page, actually. I was trying to get your 
attention, Mr. Chairman.
    [Laughter.]
    Senator Reed. You have my attention.
    Senator Allard. I told you I had 30 pages.
    Senator Reed. Knowing of your concise and focused comments, 
I trusted you did not.
    Senator Allard. Very good. I ask unanimous consent that my 
statement be made a part of the record. I just have a one-page 
statement. I will just make it a part of the record.
    Senator Reed. Without objection, it shall be a part of the 
record. Now let me introduce the panel.
    Dave Jacobs is the Director of the Office of Healthy Homes 
and Lead Hazard Control. Before that he was Deputy Director of 
the National Center for Lead-Safe Housing, from 1992 to 1995. 
He has received a number of awards for his work on lead hazard 
reduction.
    Mr. Thomas L. Sansonetti is the Assistant Attorney General 
in charge of the Environment and Natural Resources Division at 
the Department of Justice. Prior to arriving at the DOJ, Mr. 
Sansonetti was a partner in the Cheyenne office of Holland & 
Hart, where he specialized in natural resource and 
environmental law.
    Mr. Adam Sharp is the Associate Assistant Administrator, 
Office of Prevention, Pesticides and Toxic Substances at the 
Environmental Protection Agency. Prior to that, he worked at 
the American Farm Bureau Federation on its governmental 
relations and regulatory affairs staff. He also served as a 
Director at the federation for the last 2 years of his tenure 
there.
    Mr. Ruben King-Shaw is Deputy Administrator and Chief 
Operating Officer, Centers for Medicare & Medicaid Services. 
Prior to assuming this responsibility, he was the Secretary of 
the Florida Agency for Health Care Administration.
    Mr. Dick Jackson is the Director of the National Center for 
Environmental Health, one of the centers within the Centers for 
Disease Control and Prevention. He is a pediatrician who has 
spent the past 25 years working to improve the health of 
children. He has also served as a State health official and as 
Chairman of the American Academy of Pediatrics Committee on 
Environmental Health.
    Before you begin, I would like to thank each of you for 
your written testimony, which has been shared with the Members 
of the Subcommittee. And I would ask that you stick to our 5-
minute time limit, if you would. And you may in fact make your 
statements in whole part of the record.
    Thank you, and let's begin with Mr. Jacobs.

              STATEMENT OF DAVID E. JACOBS, Ph.D.

               DIRECTOR, OFFICE OF HEALTHY HOMES

                    AND LEAD HAZARD CONTROL

        U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT

    Mr. Jacobs. Thank you, Mr. Chairman, Senator Allard, for 
the opportunity to appear before you today to discuss HUD's 
activities in the area of childhood lead poisoning prevention.
    My message today is simply this--the Nation has, in fact, 
made enormous progress. However, much more remains to be done. 
And the science and the practical program experience that we 
have accumulated shows that we know how to do it.
    Over the past decade, the number of houses with lead-paint 
hazards has declined at an astonishing rate--from 64 million 
houses in 1990 to 38 million--as you just noted. That is an 
enormous decline and it is the best proof yet that what we are 
doing is actually working.
    Yet, the challenge of eliminating hazards before children 
are poisoned remains quite large. And if we fail to finish the 
job, hundreds of thousands of children will be unnecessarily 
poisoned in the coming decade. That must not be permitted to 
happen.
    The Administration is committed to eliminating childhood 
lead poisoning by the year 2010, and I am pleased to tell you 
that the Administration has continued the Executive Order that 
established the President's Task Force on Children's 
Environmental Health and Safety Risks, which produced the 10-
year plan to eliminate the disease.
    I am also pleased to report that HUD Secretary Mel Martinez 
has made this a priority of his administration, and it shows. 
We are creating thousands of lead-safe houses each year, more 
than ever before. We have trained over 28,000 housing rehab and 
maintenance workers in lead-safe work practices over the past 
year alone.
    With Congressional support, we have increased HUD's lead 
hazard control budget by 10 percent for 2002, and the 
President's budget proposal for 2003 increases it by another 15 
percent, which will enable even more houses to be made lead-
safe.
    Housing receiving Government assistance, according to our 
new national survey, has been made about as safe as the middle- 
and 
upper-income housing--that is, low-risk housing--evidence that 
our lead-paint regulation for Federally-assisted housing works.
    We believe that regulation also provides an important model 
for the rest of the Nation because it takes action before a 
child is poisoned, not just after the child is already 
poisoned. And it proves that if we put our mind to it, we can, 
in fact, make our houses safe for children across the entire 
country.
    I want to briefly highlight several key ingredients to what 
we think is the solution--local know-how and capacity, 
enforcement, proof of what works, and the importance of 
partnerships among the Federal agencies. And I want to close 
with HUD's new initiative 
to leverage private-sector resources, something we call 
Operation LEAP.
    First, our grant program is the main vehicle in the country 
for dealing with the houses with the greatest hazards. These 
are low-income, dilapidated, privately-owned houses that 
usually receive no other form of Government assistance.
    Today, the HUD program is active in over 200 jurisdictions. 
In 1990, only one or two jurisdictions had much in the way of a 
significant program that actually fixed low-income, privately-
owned houses.
    It will come as no news to Senator Reed that Rhode Island 
is, in fact, one of our best performers in this area. But there 
are hundreds of other jurisdictions now across the country that 
have the know-how to get the job done, and that is as a direct 
result of the HUD grant program.
    Second, on enforcement of the disclosure rule to ensure 
that parents get the information they need to protect their 
children, we have had what I would describe as a truly 
wonderful relationship with the Department of Justice, with 
local law enforcement, health and housing agencies, and with 
EPA to target our enforcement 
actions to the most egregious cases. In fact, the Secretary has 

increased our staffing at HUD to further expand our enforcement 

activities.
    Proof. How do we actually know that any of this really 
works? We have conducted the Nation's largest study of modern 
lead hazard control techniques. And I could not resist showing 
you one scientific slide, at least.
    [Slide.]
    This slide basically shows that in approximately 2,700 
housing units that we studied, dust-lead levels, which are the 
main predictor of children's blood-lead levels, have declined 
and stayed low, even though all lead-paint has not been 
removed. So this is clear evidence that, in fact, what we do 
works. We also, I might add, measured children's blood-lead 
levels who lived in those units, and that declined by 26 
percent in one year.
    Coordinating with other agencies makes our work more 
focused and productive. For example, in Manchester, 
Connecticut, I know that Senator Reed mentioned Medicaid. In 
that community, children who have high blood leads are 
automatically referred to the HUD lead grant program to make 
sure that their housing units are lead-safe.
    In Chicago, when the Centers for Disease Control conducts 
its high-intensity targeted screening program that Dr. Jackson 
will discuss later, HUD's lead-paint grantee was there to make 
sure that the units were safe.
    HUD and EPA have worked together to target regulations so 
that we use abatement contractors only for the highest-risk 
houses, not for routine housing rehab and maintenance work. But 
we do make sure that rehab and maintenance workers do get the 
training they need to get their jobs done safely.
    Housing programs not covered by Title X, such as the 
Department of Energy's Weatherization Program, and States 
administer-
ing low-income housing tax credits that are used for 
rehabilitation, can use that training curriculum or the workers 
that we have 
already trained so that they do not have to reinvent the wheel. 
In fact, in California, Wisconsin, and elsewhere, many of our 
grantees combine weatherization work with lead hazard control 
work to get the job done and stretch the dollars.
    And finally, we believe increasing private-sector 
involvement is a critical part of the solution. Within the next 
2 to 3 weeks, HUD will be releasing a notice for funding 
availability for Operation LEAP, which stands for Lead 
Elimination Action Program.
    Grants will be awarded to entities that can leverage 
private-sector investment, and so we hope that banks, hardware 
stores, community groups, landlords, and others will respond 
favorably to help solve this problem.
    In conclusion, let me recognize Senator Reed for his truly 
outstanding leadership on this issue. Your resolve and 
commitment have been a tremendous help to America's children 
over the years. So thank you.
    Senator Reed. Thank you, Mr. Jacobs.
    Mr. Sansonetti.

               STATEMENT OF THOMAS L. SANSONETTI

                   ASSISTANT ATTORNEY GENERAL

           ENVIRONMENT AND NATURAL RESOURCES DIVISION

                   U.S. DEPARTMENT OF JUSTICE

    Mr. Sansonetti. Chairman Reed, Senator Allard, I am pleased 
to be here today, along with my colleagues on the panel, to 
discuss what the Department of Justice is doing to protect 
America's most important resource, its children, from lead-
based paint poisoning.
    In my testimony today, I will focus primarily on the 
Department's enforcement efforts in connection with the 
initiative developed by our colleagues and clients at HUD and 
EPA. This initiative is providing tangible improvements in the 
lives of some of our most disadvantaged children. Of course, I 
would be happy to answer any questions that the Subcommittee 
may have.
    Mr. Jacobs has pointed out, lead poisoning is a significant 
health risk for young children and lead poisoning is especially 
acute among low-income and minority children living in older 
housing.
    This public health problem was the genesis of the Federal 
Residential Lead-Based Paint Hazard Reduction Act, which 
requires the sellers, owners, and managers of residential 
buildings built before 1978 to warn prospective buyers and 
tenants about the likely presence of lead-based paint and lead 
in dust or soil on the property. It also requires landlords to 
give tenants an EPA pamphlet about how to minimize the dangers 
to children, and directs them to document their compliance with 
the law by keeping tenants' signatures on file using a standard 
disclosure form.
    In regard to the enforcement initiative, this Act is no 
different, frankly, than any other law in that it requires 
strong and fair enforcement to ensure that legal goals become 
practical realities. It is also important that law-abiding 
landlords and management companies have a level economic 
playing field on which to compete, and that those who fail to 
comply with the law know they will be penalized. Accordingly, 
HUD embarked on a civil enforcement initiative to ensure 
compliance with the Act's requirements after its effective date 
in 1996. It focused its enforcement actions on four major 
cities--Los Angeles, Chicago, New York, and the District of 
Columbia--and proceeded by targeting large management companies 
responsible for buildings which were covered by the Act and had 
multiple incidents of lead-poisoned children. EPA also has a 
lead coordinator in each of its 10 regions responsible for 
lead-paint enforcement.
    This simple but effective strategy helped the agencies 
quickly identify those who were responsible for some of the 
biggest lead-paint related problems. Now based on this 
footwork, HUD and the EPA began filing a series of 
administrative enforcement actions against violators of the 
Act, and then also referring cases to the Department of Justice 
for judicial enforcement actions.
    The hard-working people at HUD, EPA, and the U.S. 
Attorneys' offices have made this initiative a success. I think 
they have done a remarkable job in developing investigative 
strategies and putting in the many hours that it takes to turn 
a good plan into great results. One of the things that Senator 
Reed asked me to address was how DOJ can interact more efficiently 
with other agencies to eliminate lead-based paint poisoning in 
children, and I am happy to tell you that we are already working 
very well with them to achieve this important goal.
    The State attorneys general and the State and local lead 
poisoning enforcement agencies are also essential players in 
this enforcement effort. In fact, our cases get started when we 
receive reports of elevated blood levels of lead from a local health 
department. So thanks to their efforts, I have some major success 
stories to talk about, both civilly and criminally.
    We have pursued several cases judicially here in the 
District and across the country. One big success story came 
last October when DOJ, HUD, and EPA announced settlements in 
cases against three landlords in Chicago for failure to warn 
their tenants that their homes may contain lead-based paint 
hazards. These companies controlled nearly 10,000 apartments, 
and they agreed to test for and cleanup any lead-based paint 
found in their properties, and pay $90,000 in penalties. One of 
the companies also agreed to pay $100,000 to Chicago's Health 
Department as part of a child health improvement project, and 
the other two agreed to give $77,000 to a community-based 
health center to provide free blood testing for children living 
in Chicago and South Chicago.
    We have simultaneously announced settlements in four 
administrative cases against landlords in New York and Los 
Angeles that own and manage approximately 6,500 units.
    In criminal prosecutions, what started out as a civil 
enforcement initiative has also produced the first-ever 
criminal lead-paint prosecutions in the last year. The first 
involved David Nuyen, a 
Washington-area landlord who owned and managed 15 low-income 
rental properties in the District of Columbia and Maryland. HUD 
contacted Nuyen in September of 1998 as part of our enforcement 
initiative. His response was to present the Agency with 
falsified, forged, and back-dated lead-paint forms that made it 
appear that he had given tenants the required hazard warnings 
when he had not, even though he had previously received notices 
of violation that his apartments had dangerous levels of lead. 
He was convicted in July of last year, sentenced to 2 years in 
prison, and a $50,000 fine.
    Another similar prosecution culminated in March in New 
Hampshire, a gentleman named James Aneckstein sentenced in 
Federal district court, 15 months of incarceration, $40,000 
criminal fine. He also failed to notify his tenants of the 
presence of lead-paint. But in this case, one of the tenants, a 
2-year-old girl named Sunday Abek, died of that lead poisoning.
    In conclusion, tragic deaths such as Sunday Abek's are 
completely preventable. We are proud to be working with our 
partners at HUD, EPA, the U.S. Attorney's offices, the FBI, and 
State and local enforcement agencies, to bring them into this 
initiative to protect America's kids, especially those 
disadvantaged ones who are at the greatest risk.
    And I am pleased to tell the Senator that yesterday, we 
lodged another consent decree against a Chicago landlord who 
had failed to notify his tenants of lead-paint in his units.
    So with your continued support, we believe that we can move 
a long way toward eliminating lead poisoning, and I look 
forward to working together with the Subcommittee on this 
important issue, and to answering any questions that you may 
have.
    Senator Reed. Thank you, Mr. Sansonetti.
    Mr. Sharp.

                    STATEMENT OF ADAM SHARP

               ASSOCIATE ASSISTANT ADMINISTRATOR

             OFFICE OF PREVENTION, PESTICIDES, AND

                        TOXIC SUBSTANCES

              U.S. ENVIRONMENTAL PROTECTION AGENCY

    Mr. Sharp. Thank you, Senator.

    Mr. Chairman, my name is Adam Sharp. I am the new Associate 
Assistant Administrator at the Office of Prevention, 
Pesticides, and Toxic Substances.
    Thank you for the invitation to appear before you today. It 
is my privilege to be here today with our partners to discuss 
our joint 
efforts to prevent lead-based paint poisonings of our Nation's 
children. I am going to quickly summarize my testimony and ask 
that my full testimony be entered into the record.
    Senator Reed. Without objection.
    Mr. Sharp. Thank you.
    In the almost 10 years since Title X was enacted, EPA, 
together with HUD, HHS, and Justice, as well as our State 
partners, have made significant progress in eliminating 
childhood lead poisoning. While we still have a significant 
challenge, particularly with minority children and children 
living in low-income housing, EPA is very proud of how the 
Federal agencies and our State and private-sector partners have 
coordinated their efforts.
    For example, the Federal Government has phased out lead in 
gasoline, reduced lead in drinking water, reduced lead in 
industrial lead pollutants, and banned or limited lead used in 
many consumer products, including paint. States and 
municipalities have set up programs to identify and treat lead-
poisoned children and to rehabilitate deteriorating housing. 
Parents, too, have greatly helped to reduce lead exposures to 
their children by cleaning and maintaining homes, having their 
children's blood-lead levels checked, and also promoting proper 
nutrition.
    As you can tell from the individuals at the table today, 
combatting lead is a multifaceted and coordinated approach. 
EPA, as well as other agencies here today, have a variety of 
activities underway. Let me provide an update on those 
activities at the Environmental Protect Agency.
    EPA's primary goal is to prevent children from being 
poisoned and avoiding the consequences associated with it. The 
basic program includes a national regulatory infrastructure 
involving our State and local partners, developing outreach and 
education programs aimed at those most at risk, educating and 
assisting those who can help address the problem, and focusing 
on how our children can be better protected.
    In the area of regulations, EPA, together with HUD, have 
been very busy. Let me turn to a few of the highlights.
    First, in 1996, EPA and HUD jointly promulgated a rule to 
ensure that lead-based paint information is disclosed during 
real estate sales and rentals, specifically for those houses 
built before 1978. This rule ensures that the homebuyer or 
renter has a right to available hazard information and a right 
to lead inspection if 
desired.
    Second, also, in 1996, EPA promulgated a rule covering the 
professionals who work in the lead inspection and abatement 
profession. It also ensures that a well-trained cadre of lead 
inspectors, risk assessors, and abatement personnel are 
available. This same rule also allows EPA to authorize States, 
Tribes and Territories to develop and administer training and 
certification programs. At present, 36 States, Puerto Rico, two 
Tribes, and the District of 
Columbia are assisted by Federal grants, are authorized to 
carry out this program, and EPA is working with others.
    Third, in 1998, EPA promulgated another rule to ensure that 
all owners and tenants of pre-1978 housing be given basic 
information about lead poisoning prevention prior to 
renovations that may disturb lead-based paint.
    Fourth, in 2001, EPA promulgated another rule to define the 
specific levels of lead in dust and soil that are most likely 
to pose a health threat to children. These scientific standards 
help to determine when and how to clean up lead dust, lead-
paint, and lead soil problems.
    Let me now turn to education and outreach.
    Education outreach is also a very important component of 
our lead program. We work as much as possible with our 
customers and our stakeholders in several areas, including the 
development of regulations, assisting regulated parties in 
complying with regulations, informing citizens of their rights 
under these rules, informing the public about lead-based paint 
hazards, and providing guidance on how to reduce risks. Our 
partners at HUD and CDC 
partially fund these activities and provide technical support.
    Some of these outreach efforts include the bilingual 1-800 
National Lead Information Center. This is a national 
clearinghouse to educate workers and the public about lead 
hazards and abatement precautions. The development of materials 
such as brochures and sample real estate disclosure forms 
needed to comply with regulatory requirements. The creation and 
distribution of education materials and national lead awareness 
campaigns for parents, homeowners, renters, medical 
professionals, renovation contractors, and do-it-yourselfers.
    EPA also has done important work in scientific capacity. 
For example, EPA had conducted numerous studies to define the 
levels of exposure that should be regarded as hazardous to 
children and identify work practices that successfully reduce 
lead-based paint risks. EPA's goal is to better understand lead 
exposures, ensure that testing is done appropriately, and 
reduce the costs associated with eliminating exposure.
    Even though we have accomplished a great deal of things, 
there is still more to be done. Let me now turn to a few other 
regulatory activities.
    EPA anticipates completing the regulatory program mandated 
by Title X over the next few years. So what are the next steps? 
Our renovation and remodeling activities will address how to 
safely remove lead-based paint and debris during remodeling 
activities. We anticipate that this proposed rule will be ready 
for publication in 2003.

    EPA has already developed a model training course and other 
materials for renovation contractors and homeowners, which is 
intended to provide them with recommended methods to minimize 
lead hazards.

    Further, of lead-based paint abatement activities on 
bridges and structures, we expect to publish a proposed rule in 
2004.

    The Agency also expects to finalize regulations on 
management and disposal of lead-based paint debris by the end 
of this year.

    Thank you for the opportunity to discuss some of EPA's 
contributions to prevent lead-based paint poisonings, just a 
part of our successful collaboration on this issue. Again, I 
want to thank you for your support and assure you that this 
Administration is looking forward to working with this 
Subcommittee to achieve our goal of eliminating childhood lead 
poisonings by 2010.

    Thank you.

    Senator Reed. Thank you, Mr. Sharp.

    Mr. King-Shaw.

               STATEMENT OF RUBEN KING-SHAW, JR.

        DEPUTY ADMINISTRATOR AND CHIEF OPERATING OFFICER

            CENTERS FOR MEDICARE & MEDICAID SERVICES

    Mr. King-Shaw. Thank you very much, Chairman Reed, and to 
the Subcommittee, I, too, would like to offer a verbal summary 
and submit my written testimony for the record.

    Senator Reed. Without objection.

    Mr. King-Shaw. It is a pleasure for me to be here to share 
with you and the Subcommittee and others what CMS is doing on 
this important issue of lead-based paint poisoning in children.

    As the providers of Medicaid programs with a partnership 
with the State, this is quite an important effort for CMS. This 
issue affects low-income children, particularly in underserved 
ethnic communities in older housing. As such, it is a part of 
our overall effort to eradicate all health care disparities 
through our programs.

    As you are committed, Chairman Reed, our Secretary, Tommy 
Thompson, Administrator Scully, myself, and all of us at CMS 
have a true and long-standing commitment to the preservation of 
health and the protection of health in children all across 
America. We work toward that goal through our Medicaid program 
directly, but we also coordinate with my colleagues at other 
Federal agencies and community-based organizations that are 
active on this issue.

    The Medicaid program itself has very specific benefits and 
coverage regarding the screening and detection and treatment 
for lead-based paint poisoning in Medicaid-eligible children. 
Briefly, Medicaid-eligible children must be tested at 1 and 2 
years of age as part of the Medicaid benefit. And again, if 
there is no record of a test for children between the ages of 2 
and 6 years, that that test must also be provided for untested 
children in that age group.

    Specifically, the Medicaid program pays for the testing, 
the diagnosis, the treatment, the case management services, and 
a one-time environmental investigation of the primary residence 
when a child's test reveals elevated blood levels for lead.
    In 1999, you are aware, I am sure, of a GAO report that 
identified some challenges and some issues with the Medicaid 
program in providing this benefit. And since then, we have done 
some things to address some of the issues presented in that 
report. I will just share a few of them with you in the time 
that I have remaining.
    Lead screening is a part of a comprehensive program known 
to many of you, Medicaid's Early and Periodic Screening 
Diagnosis and Treatment Program, or EPSDT. The EPSDT reporting 
system is generated by the States. It is rolled up as a 
statewide report and then given to us at CMS. Some time ago, as 
a result of some of these struggles, we added a line item that 
gives us specific indication of States' compliance with the 
lead screening program, and we monitor that rather closely.
    We have also communicated directly to the States on two 
separate occasions urging them to share information on best 
practices along these lines, and also informing and reminding 
them of the 
responsibilities of State Medicaid agencies to administer the 
Medicaid benefit effectively and to adhere to the current 
policy of universal screening.
    We have joined hands with a community-based organization, 
the Alliance to End Childhood Lead Poisoning, to do a couple of 
important things.
    One, we have developed an education tool that is used 
throughout the country to encourage States and local entities, 
as well as providers on the importance of this issue. And together, 
we have written a guide, an important guide entitled, Track, 
Monitor and Respond: Three Keys to Better Lead Screening for 
Children in Medicaid. We believe these are positive differences 
that we are making in outreach and compliance nationally.
    We also have engaged a contractor to conduct site visits 
around the country, including Providence, Rhode Island, as you 
know, Mr. Chairman, Baltimore, Maryland, Chicago, Illinois, the 
State of Iowa, and Oakland and Alameda County, California, to 
try to find the best ways to make sure that our programs are 
well communicated and in full compliance.
    We, too, collaborate on the Federal level, including being 
an active part of the President's Task Force on Environmental 
Health Risks and Safety Risks to Children, and we hope to build 
better relationships with the colleagues around this table. And 
we have begun to do great work with our colleagues here as 
well.
    We remain committed to the current policy until and unless 
we receive guidance from our colleagues over at the Centers for 
Disease Control that would warrant a change. The Secretary is 
awaiting those recommendations; you will hear more about that 
work, perhaps, from my colleague at the CDC.
    But in the meantime, our challenges remain in the 
compliance area and we can talk about some of the things we can 
do there. And we remain committed to making sure that, to the 
best of our ability, we communicate with our provider partners 
and States to administer the current policy effectively for the 
better protection of all children in this country.
    Again, I want to thank you for the opportunity to share 
these comments with you. I look forward to a good discussion 
and to providing vital information to you in the period that 
follows.
    We remain committed to serving all children in America 
through the Medicaid program as defined by law and statute.
    Thank you.
    Senator Reed. Thank you, Mr. King-Shaw.
    Dr. Jackson.

                          STATEMENT OF

           RICHARD J. JACKSON, M.D., M.P.H., DIRECTOR

            NATIONAL CENTER FOR ENVIRONMENTAL HEALTH

           CENTERS FOR DISEASE CONTROL AND PREVENTION

          U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Dr. Jackson. Thank you, Senator. And thank you very much 
for the important leadership that you have provided on this 
issue of childhood lead poisoning. Many of the comments, even 
in my oral testimony, have already been made and I am going to 
summarize my comments for you and ask that the written document 
be placed in the record.
    Senator Reed. All of the statements will be made part of 
the record. In addition, Senator Stabenow wished that her 
statement be part of the record, too.
    Dr. Jackson.
    Dr. Jackson. Thank you very much. The five major points I 
want to make are.
    First, just the clinical, medical importance of lead.
    Second, the importance of good data. If you want to make 
decisions, you have to have good data.
    Third, the importance of primary prevention, not having 
lead in the child's environment.
    Fourth, will be the importance of partnerships. This is too 
big and too hard to do alone by any one Agency or any one 
group.
    Fifth, some new tools to really grapple with this issue of 
childhood lead poisoning in the pocket that is left.
    When I was a medical student in New Jersey, I did a 
rotation in New York at Mt. Sinai. The first day on the 
pediatric ward, they took me around and there were 25 little 
kids running around, as hyperactive as could be. This is the 
early 1970's. They were receiving kelation. They had blood-lead 
levels in the 50, 60, 70 range. They were receiving very 
expensive, in-hospital, drug therapy for the treatment of their 
lead poisoning. And I said to the senior physician, this is 
terrible. He said, wait till you see this. And he took me into 
a back room and there was a child with a swollen brain, 
convulsing, who ultimately died of lead poisoning.
    The city of New York alone had 10 kids a year that would 
die of lead poisoning in the late 1960's. This was a desperate 
problem. And most of us in the country had blood-lead levels in 
the range of about 20--two zero.
    We have had, and thanks to the partners at this table, EPA, 
particularly with lead coming out of gasoline, FDA, EPA with 
paint issues, Consumer Product Safety Commission, and the rest.
    This is probably, what I am showing to you here, the 
environmental health success story of the last half century. 
This is actual measurement of lead in the bodies of Americans. 
And I will ask to have this put over on the side.
    [Slide.]
    But it is a graph of blood leads dropping from an average 
of 16 in 1974, to a blood lead of, on average, two right now. 
It is lower than was thought to be feasible on the face of the 
earth.
    The good news is we are not seeing the same extensive level 
of poisoning in our population. The bad news is we have between 
a half-million and 750,000 children who are left. They are the 
most difficult children to reach. They are in the poorest 
houses in the poorest neighborhoods. Sitting back and waiting 
for them to show up in clinic is not going to be an adequate 
approach to dealing with this residual population with lead 
poisoning.
    My second major point--oh, I want to make one quick other 
point about that blood lead.
    Our current definition of elevated blood lead is a blood 
lead of 10. There is a fair amount of scientific information 
and pressure to reconsider that level and to reduce it. We have 
asked the Advisory Committee on Childhood Lead Poisoning to 
pull all the relevant scientific data to have the experts come 
in and speak to that. That is an advisory committee to the 
Secretary and they will make formal recommendations as to what 
a proper definition would be.
    The second issue of good data, and I give you an example 
here of just how powerful this is in making decisions. But it 
also means that we have to have data from local communities. We 
have to know where the hot spots for lead poisoning are, higher 
in this area, lower in that area. You cannot make a good 
decision about where to either start or stop screening without 
good data. The guidelines that we put out in 1997--these are 
screening young children for lead poisoning guidelines for 
State and local health officials--essentially, we do not want 
to stick needles in children.
    So the guidance here is when you find out that you have 
done enough testing and there is not a problem, you can stop 
doing lead testing in parts of the communities that do not have 
a problem. And that is the guidance that we have offered.
    The third quick point is just primary prevention is 
critical. Sitting back and trying to figure out which houses to 
clean up by looking at poisoned children is not adequate. We 
need to go after the houses, clean up the houses. In Minnesota, 
they are now identifying homes where poor women become 
pregnant, and do the clean up much earlier rather than waiting 
for a child to appear lead-poisoned, and then going in and 
retrospectively trying to undo it.
    The fourth quick point--partnerships are the only way to do 
this. This Federal strategy that was put together by all these 
agencies has to occur. This is not going to be done by medical 
groups alone. It is not going to be done by housing alone, EPA 
or anyone else alone. They all have to work together. This is 
much too complicated or difficult for any single, isolated 
Agency to do and that national leadership is important.
    We, CDC, are funding 43 States and 17 local health 
departments for intensive lead programs.
    And last, new methods--this is actually a very old method--
the new method is we are calling it HITS--High-Intensity 
Targeted Screening. We did it late last year in two inner-city 
areas in Chicago where we put teams together, public health 
nurses, housing specialists, other community people. We 
actually put them out into the community, going house to house, 
finding the kids, doing the lead screening, looking at the 
paint in those houses.
    Sadly, what we are finding is two-thirds of the children in 
those homes, in those high-risk homes, have never been screened 
for lead. One-third of the children, when we do a lead 
screening, have elevated blood leads.
    And so, the point I want to make here is that we are 
dealing with the hardest and most difficult. The tradition a 
lot of times in dealing with public health problems is we push 
the levels down, down, down, like the tuberculosis and others, 
and we figure, oh, we are almost done, and we lose the 
attention on that issue. And that is exactly the wrong time to 
stop. That is when you really have to push harder because it is 
a harder group to deal with.
    Thank you so much for your attention and your leadership on 
this, Senator.
    Senator Reed. Thank you, Dr. Jackson.
    We have been joined by my colleague, Senator Corzine. 
Senator, do you have an opening statement, or comments?

               COMMENTS OF SENATOR JON S. CORZINE

    Senator Corzine. I do, Mr. Chairman, but I will submit it 
for the record. The discussion you were having with the panel, 
and I thank them for their participation and thoughtful 
presentations.
    This is a really go-to issue, in my opinion, one that, as 
the last panelist just remarked, we are down to the really 
tough parts, but it makes a huge, huge difference in the lives 
of an important segment of our population.
    I think about a number of our urban communities in Newark, 
which I have extensive comments on. Estimates are that 9 out of 
every 10 houses in the city of Newark are tainted. We have 
worse numbers in Camden. The communities that are most 
desperately in need in almost all areas show up as the hot 
spots with regard to lead-based poisoning of kids.
    Then we are concerned about how poorly children do in 
school. And we are not looking at how the holistic approach of 
dealing with these various problems are. So, I think you are 
doing God's work here by making sure that this issue is raised 
to a national debate that we stay fixed on it and pushing 
forward with it.
    Thank you.
    Senator Reed. Thank you very much, Senator Corzine. And 
your full statement will be made part of the record.
    Let me begin the questioning, and I will take some time and 
then recognize my colleague, Senator Corzine.
    In response to Dr. Jackson's comments about the fact that 
they have been looking and finding in low-income neighborhoods 
children who have not yet been screened and the overall level 
of screening is about 20 percent.
    I think, Mr. King-Shaw, you were anticipating my question. 
I was quite honestly startled a few months ago when the 
Administration was talking about giving the States the option 
to screen or not to screen without any type of data. In fact, 
all the data suggests that we are not doing enough screening. 
Could you just try to indicate what prompted that? I know it 
has been reversed by Secretary Thompson, but what was the force 
or the emphasis that was leading to even that type of 
discussion?
    Mr. King-Shaw. First, let me say that there had never been 
a decision at CMS or HCFA, prior to our changing the name, to 
make a change in that policy.
    We were receiving requests from States--Utah, Alaska, among 
them--to do something different than what is our current 
policy, to develop ways of targeting those resources into the 
high-risk areas. And so, the discussion was generated by an 
interest that came to us from States and clinical communities 
around the country, who asked us to consider doing screening in 
different ways. This conversation, then, began in responding to 
them. We clearly did not make any specific attempts to change 
the policy by rule. In fact, in all of the discussions we were 
having with States and clinical communities, we were very clear 
about the fact that we were waiting for the Secretary's 
advisory commission over at CDC to give us some guidance.
    If there were going to be any changes, they would have to 
be generated from the advisory panel based on the evidence, 
research, and some type of data assessment indicating that 
potential existed to do anything different than what we were 
doing today.
    But absence of that recommendation, until there is a 
recommendation, there is no effort on the part of CMS to change 
the policy. What you heard was a conversation; CMS responding to 
people interested in doing something different than our current 
policy. And the States generated that discussion as part of the 
waiver or State plan amendment request process.
    Senator Reed. Well, we seem to agree that that was a very 
bad idea. There is a good idea--in fact, it is the law--that 
100 percent of Medicaid children should be screened. We are 
only screening approximately 20 percent. So let me ask what 
your Agency is going to do to ensure that 100 percent of 
children are screened, as required by the law?
    Mr. King-Shaw. Some of what I have already shared is a 
direct communication effort to remind not just the State 
agencies, but also provider groups and community-based 
organizations of the importance of doing this.
    And so, the outreach, the education is about not only the 
clinical importance of this, but also the mandate as part of 
the Medicaid benefit and the policy for universal screening.
    Now part of what is limiting our ability to achieve full 
compliance here is that we currently have very few powers to 
enforce this kind of provision, and the enforcement powers we 
do have are rather Draconian.
    One option would be to withhold Medicaid funds from the 
State's Medicaid program. That is a very severe measure to take 
because it would not be segmented from most of the other 
Medicaid benefits. We are talking about cutting off large 
States from Medicaid funding in its entirety for child care 
services. And I do not know whether people would like to see 
that happen as an enforcement measure.
    The other option that we are trying is working with States 
to improve their reporting and analysis in both the fee-for-
service Medicaid environment and the managed-care Medicaid 
environment.
    Our reporting is largely based on claim status. When a 
claim is paid for a lead screen, then we pick that up in our 
claim system. In cases where we contract with a managed care 
organization, we do not receive that claim information, but 
rather encounter data. So that we are relying on data that 
comes in from the States, which may not be as accurate because, 
in part, managed care organizations often struggle to get the 
information out of their provider network and to forward it 
over to us.
    Moreover, a significant number of children get screened in 
local health departments, which, for a variety of reasons, may 
not bill us at all for the service. And when that happens, we 
do not receive good, reliable information on States' screening 
performance and what they are finding out from that screening 
performance.
    But we are working on data collection. We are working 
directly with States, provider organizations, community-based 
organizations, and our regional offices to try to do a better 
job at achieving full compliance.
    Senator Reed. Let me ask one additional question before I 
move on to the other panelists. In your description of the 
managed care arrangement, my presumption would be that part of 
their contract is to screen Medicaid children 100 percent. 
Would that be a correct assumption?
    Mr. King-Shaw. Actually, our information shows that 
approximately 42 percent of contracts between managed care 
organizations and the State have specific language on lead 
screening.
    Now there is another body of contracts that address the 
EPSDT program in general and this is a part of that program. 
So, therefore, by extension, it is addressed.
    So our best information would be that virtually all of the 
contacts have some provision, either direct or indirect, that 
would call for this kind of screening.
    States do take the primary responsibility in monitoring and 
in compliance with the Medicaid contract; they have teams and 
State agencies that do that. Our regional offices get involved 
in looking at that data. So the contract between the State and 
the managed care organization does give us some contractual 
relationship that we can monitor and drive compliance.
    Senator Reed. Not only monitor. Enforce. If you are paying 
Federal dollars to a managed care company that is not 
performing the services that you contracted for, I suspect you 
could enforce it. But let me move on.
    If you could recommend to this Subcommittee specific 
enforcement powers that you think would be appropriate, short 
of the Draconian enforcement of denying Medicaid payments, we 
would appreciate that very much. In fact, I would ask you to do 
that.
    Mr. King-Shaw. Now? Here?
    Senator Reed. No, at your convenience. Promptly, but not 
here.
    Mr. King-Shaw. I would be pleased to do so. Thank you, 
Senator.
    Senator Reed. Thank you.
    Let me ask Mr. Sharp. The EPA has been charged over many 
years to develop regulations. And you have indicated in your 
testimony that you are beginning that process. At least 10 
years ago, EPA was asked to create a rule with respect to 
remodeling and renovation. A lot--or some, at least--of the 
problems encountered are a result of remodeling and renovation.
    We were in Maine in field hearings with Senator Collins. 
Where a young woman had talked about how she bought the house 
of her dreams, an old Victorian, and she had two young children. 
And in the process of renovation, poisoned her children. So it 
is a real problem. Can you update us now on the process of those 
regulations?
    Mr. Sharp. Yes. Actually, I outlined four other regulations 
of course in my testimony that we have been working on and 
completed. We have three more, this being one of those.
    We are on target to publish that rule next year. There is a 
number of things, of course, we have been working through. And 
we have completed a lot of the preliminary work on getting this 
rule done. Technical studies have determined the scope of the 
problem. It was one of the first major undertakings that we had 
to do and have completed those.
    Guidance and training courses, identifying best practices 
is another portion that we have been working through, and then 
prerenovation materials and education of consumers. Materials 
like these, Reducing Lead Hazards When Remodeling Your Home. 
This is dated 1997. There is a number of materials like this 
that already are out there, and I want to make sure that that 
is a good, clear point.
    There are a number of things that we have been doing even 
before this rule comes out to address this issue, particularly 
with the remodeling concerns that you have outlined. So there 
are a number of things that we are trying to do.
    We are also trying to work with our State partners to 
identify those particular areas as well, where you may have 
more concern, and we have talked about that a lot, where there 
may be specific communities of people who are more at risk than 
others. We have been trying to work with our State partners. I 
mentioned that we have about 35 States now that we are working 
with, three Tribes, Puerto Rico, and the District of Columbia, 
to achieve that.
    So, we are on target with the remodeling and renovation 
rule of getting it out next year. We are also going to be 
meeting with a number of stakeholders, our States and others, 
through the later part of this summer and the fall, to also 
further develop and make sure that we have all the right types 
of programs in place for this rule. Of course, the bottom line 
for putting out a new rule is that it needs to be effective. It 
needs to be a rule that is going to have compliance. People 
need to be able to look at this and comply with it, be able to 
understand it. It needs to be flexible. It needs to be 
innovative.
    We need to make sure that people in that last portion of 
the graph are the people that this works for.
    You can put out a rule and if it doesn't have the right 
components in it, it can sit there. And what we want to do is 
we want to make sure that we have something that is compliable, 
that people can look at and work with and make sure that it 
does have a benefit at the end. So that is what we are shooting 
for. We think we are on a good track, and with your help and 
guidance, we are going to have that out next year.
    Senator Reed. Well, I would urge you to follow through 
because it is important to get the rules out and then we can 
evaluate them, you can evaluate them and make changes. But we 
have been in this limbo for 10 years now with these rules 
required and not being promulgated.
    Let me ask another question, Mr. Sharp, and that is from 
Mr. Sansonetti's testimony about indicting and convicting 
people for failing to disclose the lead presence in rental 
apartments.
    A survey conducted by HUD in 1998 suggests that very few 
renters have ever been informed of the presence of lead. And 
there are some egregious cases in which we have taken legal 
action. But what are you doing to ensure that this rule, not 
through judicial enforcement, but administratively, is being 
obeyed?
    Mr. Sharp. EPA, in coordination between our office, the 
OPPTS 
office and our OWECA office, our enforcement office. This has 
been something that we have been working, as the gentleman 
referred to, of identifying cases in areas. And, of course, you 
do need to have these types of activities take place. You need 
to have enforcement activities in place, and enforcement 
activities taken as well, to make sure that people are 
complying.
    So, in that arena, we are trying to step up those 
approaches. We are trying to work closer with our OWECA office 
to make sure that they have a good understanding of these 
programs. Not only the four different pieces we put out within 
the last 10 years, but also the three more that we are going to 
be putting out in the next 2 years. So, I can also look to get 
you some more information on that question as well in writing 
at a later date here.
    Senator Reed. Thank you, Mr. Sharp.
    Mr. Sansonetti, let me follow-up on just a couple of 
points.
    First of all, procedurally, who makes the decision for a 
criminal action or for a civil/legal action? Is it the Federal 
attorney locally, or is it coordinated through your office here 
in Washington?
    Mr. Sansonetti. The U.S. Attorney's Offices often have the 
lead in these cases. We at the ENRD--Environment and Natural 
Resources Division--coordinate with the U.S. Attorney's 
Offices. We have meetings with them on a fairly regular basis 
to actually discuss the entire spectrum of criminal 
enforcement.
    Even just recently, last month, I was down in South 
Carolina at our National Advocacy Center, where they had 
representatives from each of the U.S. Attorney's Offices. We go 
through the entire panoply of criminal enforcement cases in the 
area of environment and then we provide the U.S. Attorney's 
Offices with the training materials to take back to their shops 
to help make these decisions.
    Senator Reed. Have you coordinated with CDC or HUD to 
identify those areas where this is a great problem?
    Mr. Sansonetti. Yes.
    Senator Reed. And have you made in those Federal districts 
the Federal attorneys aware and emphasis or at least suggest 
it, that they vigorously prosecute?
    Mr. Sansonetti. The answer is yes. As you noted from, 
actually, everyone's testimony today, these things really well 
up from the initial investigations that go on by the people at 
HUD, the EPA, CDC people, and the like.
    They do it, as I mentioned, in various and sundry ways. But 
one of the ways is to keep track of where sick kids are showing 
up. Who has the elevated blood level? Where have there been 
problems? Are they concentrated in a particular building, a 
particular area, or buildings owned by the same management 
company?
    From those investigations, the referrals come to our shop 
if, indeed, the violators have not literally cleaned up their 
act and made sure that the tenants are getting the pamphlets 
that they are supposed to get. So it is coordinated.
    Senator Reed. I just want to be clear, Mr. Sansonetti. You 
seem to be describing a process where, if the information comes 
from the field to you, you will take action.
    Mr. Sansonetti. Right.
    Senator Reed. My question is, have you looked across the 
map, if you will, based upon the data of CDC and others, and 
said, this area is really epidemic with lead poisoning, and 
suggested that the Federal attorneys take vigorous action?
    Mr. Sansonetti. The coordination actually has come--it is 
not just us to take a look at that. It is one that we take with 
EPA and HUD. And that is the core of why the initiative to date 
has indeed centered on Los Angeles, Chicago, the District of 
Columbia, and New York.
    Senator Reed. Just a final question. You have suggested and 
you have indicated some serious questions which the Justice 
Department has brought. Have you initiated any cases in the 
last year and a half ? Or are these cases that are a legacy 
from the previous administration?
    Mr. Sansonetti. The two cases that I mentioned, the Nuyen 
case was prosecuted I believe in 2001. The sentencing was just 
earlier this year. Let me make sure. The other one, I believe, 
was March. The Aneckstein case, I believe, was March.
    [Pause.]
    Yes, it culminated this March in New Hampshire, yes.
    Senator Reed. Thank you very much. Let me ask one question 
of Dr. Jackson, and then ask Mr. Jacobs a question. And then 
yield to my very patient colleague, Senator Corzine.
    You indicated, Dr. Jackson, that one of the problems is 
data collection and reliable data collection.
    CDC provides grants to States to establish childhood blood 
level surveillance systems--CBLS. Can you describe how 
successful that has been? Are the States actively collecting? 
Is it consistent? Is it reliable data? And what more do we have 
to do to make sure that the data is reliable and consistent 
across the country?
    Dr. Jackson. One is there is a lot of interest in the whole 
issue of environmental health tracking. Maybe you have even 
heard of the Pew Commission report. Senator Clinton held a 
hearing a while back on this issue of tracking, how we link 
what is going on in the environment to what is going on 
actually in people.
    There is a genuine problem in the health arena that the 
data collection systems for tuberculosis, for cancer, for this 
and that, are completely inconsistent. It is a Tower of Babel 
over here. It is worse than that. Actually, if you start 
burrowing into one of our programs, like the lead program, we 
have had inconsistency in software and other kinds of computer 
collection systems.
    The States have the ultimate authority to require 
reporting, to demand that the laboratories report, to demand 
that the counties and the doctors report. That is not an 
authority that resides with the Federal Government. The way we 
get that is through our grants process, we then require them to 
report.
    The State where I worked and had my most experience was 
California. I was involved in putting the law in place in the 
early 1980's, and foolishly, pushed for a law that required all 
blood leads over 25 to be reported to the State. It was a real 
mistake because what we really wanted to know was where lead is 
not a problem, where the kids have low levels, where did they 
have medium- and high-levels?
    We need all the lead levels being reported. A lab-based 
system is the way to go. They need to be consistent across all 
the States. They need to be linked into GIS systems, where one 
can actually go to a map and connect it to tax board data with 
other economic and social and census data. And by the way, this 
is being worked on right now actively. So you can begin to 
stack it up and figure out, this is a hot spot. We are in the 
process of doing this.
    Then when you get positive reports, say, okay, we will put 
a HITS team into this community--the nurse, the community 
organizer, and other people go house-to-house and do that kind 
of aggressive work in those areas. So, we are on track. It is 
not as good as it should be, and we are working hard to make it 
better.
    Senator Reed. Do you have the resources to make it better?
    Dr. Jackson. Right now, the program is at about $42 
million. It sounds like a lot of money when you are really 
after 50 million children and about the 600,000 that are over a 
blood-lead level of 10. Most of that money actually goes to the 
State and local programs. We withhold some for training and 
computer and other kinds of stuff. But most of it goes to the 
States.
    That is important because it is the management at the State 
and local level--the person that knows the housing people, the 
enforcement people, and the rest. They are the ones that are 
doing the real work. Lead is a local problem. We need to 
support them. But the real action is going to happen at a 
really local level.
    Senator Reed. Thank you, Dr. Jackson.
    Mr. Jacobs, let me ask you perhaps not a summary, but a 
perspective. How can we better coordinate? HUD is generally 
regarded as the lead Agency because it is a housing-based 
problem. What can we do better at the Federal level to 
coordinate from your perspective? And where should additional 
resources that are necessary be applied?
    Mr. Jacobs. Lead is one of those issues that is not within 
any specific jurisdiction among the different agencies here.
    And in that respect, one of the satisfying things that I 
have seen in my tenure with the Federal Government has been an 
increasing ability to recognize each Agency's expertise, while 
at the same time bringing their resources to bear.
    I chair the working group in the Federal task force, the 
President's Task Force on Children's Environmental Health and 
Safety Risks. We look at things such as low-income housing tax 
credits, or weatherization programs, and how to bring those 
existing programs to bear.
    I think we can do better. The Federal Government is a many-
headed beast. But clearly, the major need is to acquire the 
resources that are needed to deal with the housing stock that 
has lead-based paint hazards. That is the major expense and 
that is where the resources need to be focused.
    Senator Reed. Thank you, Mr. Jacobs.
    Let me recognize Senator Corzine, who has been most 
patient. Thank you, Senator.
    Senator Corzine. Thank you, Mr. Chairman.
    Let me ask Dr. Jackson. If the science took up to a point 
where we thought that the blood level of five, as opposed to 
10, micrograms, was the standard, how much would the population 
of those be registering relative to what I am hearing, 700,000, 
800,000?
    Dr. Jackson. Senator, I apologize for not being able to 
answer that, and I will get back to you on it. The question 
about acceptable levels below 10, the toxicity of lead, there 
is no safe level of lead. The number 10 was picked partly 
because that was as good as 
our laboratories were for running a lot of specimens at that 
time. The levels and values became relatively unstable below that. 
It was something that the programs could understand. It was in 
many ways like a speed limit. You pick a number that people can 
understand.
    But the less lead, the better. I will be happy to get back 
to you with an estimate on what a cut-off of five would 
generate in terms of numbers of millions of people.
    Senator Corzine. Do we have any preliminary understanding 
of what the implications of five might be?
    Dr. Jackson. What the neuro-toxicologists and other 
specialists in toxicology assert is actually that, when you get 
these high levels, you have saturated the brain to such a 
degree, that you do not see as big a change at the higher lead 
levels as you do at the lower lead levels. In other words, not 
a little bit is doing a fair amount of harm. And that is why 
they are pushing so hard to reexamine what is the safe 
threshold.
    From a practical standpoint--I will be very direct--I do 
not want to see the attention pulled away from the children who 
absolutely need it most in these high-risk areas by going 
after, at least from a programmatic standpoint, these much 
lower lead levels.
    We really think we have to start with the highest-risk 
kids, the kids at 20, 30, and 40, and push the program hardest 
in that direction, and then we can move to these lower levels. 
So, I am just a little worried that if the definition of an 
elevated level greatly increases it, and now we have a vast 
middle class that is chasing after it and we lose the attention 
on the kids that need it most.
    Senator Corzine. It sounds like a conundrum that I hope we 
do not have to face. I would hope that we would be committed to 
finding out and dealing with these hot spots in a more serious, 
disciplined way.
    Mr. Jacobs, if I have read the statutes right--I should 
honestly say, if my staff has----
    [Laughter.]
    The Lead-Based Paint Poisoning Prevention Act, which I 
think we instituted in 1992, established procedures to 
eliminate lead-based paint hazards in all public housing.
    I apologize if you spoke to this in your opening testimony. 
But can you give us, or give me, your view on whether we have 
solved this problem in public housing, to your knowledge, with 
regard to Section 8 housing, have we addressed this?
    Mr. Jacobs. In 1992, Congress authorized HUD to review its 
current regulations across all of our housing programs, not 
just public housing, but other assisted housing, to enable the 
implementation of modern forms of lead hazard control. That 
changed the way in which we had approached it in the past.
    We implemented that rule. There was a lengthy transition 
period to enable all of our program recipients to get up to 
speed. The Deputy Secretary ended that transition period last 
January and that rule is now in effect across the country.
    The data that we have from our housing survey show, 
surprisingly, I might add, that 17 percent of Federally-
assisted housing has lead-paint hazards. In upper- and middle-
income housing, the prevalence rate is 18 percent. The 
prevalence rate in low-income, unassisted housing is 41 
percent. And those are the houses that we target with the HUD 
grant program. Most of those houses receive no other form of 
assistance.
    So the Federally-assisted housing rules appear to work. We 
have evaluated them over time. They are based on the real-world 
experience of the HUD lead hazard control grantees across the 
country.
    It took us a while to get there. Frankly, in the mid-
1980's, it was not known, for example, that lead in settled 
dust was an important pathway of exposure. And until that was 
made clear through scientific research, we did not impose dust 
testing at the end of Federally-assisted rehab or maintenance 
work or housing finance.
    That requirement is now in place. And that is why I said 
earlier that we believe the Federal rule provides important 
lessons to the Nation as EPA moves to develop regulations to 
apply to rehabilitation activities in privately-owned housing.
    But we have done that and the evidence that we have to date 
is that it appears to be working well. It was a substantial 
undertaking. We ended up training 28,000 maintenance and rehab 
workers in the last year alone, to enable local communities to 
get up to speed so that they could comply with the rule. But 
compliance is a reality at this point.
    Senator Corzine. Section 8 vouchers, those housing units 
need to be approved with respect to lead-paint poisoning before 
the vouchers are allowed to be used in those circumstances? Is 
that correct?
    Mr. Jacobs. That is correct. The new regulation requires a 
visual examination and then if the deteriorated paint is above 
a certain de minimus level, we require the paint to be repaired 
and then dust testing at the end of the job to make sure that 
the unit is safe for children to occupy. In fact, the 
Department pays for that dust testing so that it does not fall 
to the private landlord to absorb that additional cost.
    Senator Reed. Mr. Jacobs, do you have an estimate of either 
how long or how much resources are going to be necessary to 
deal with that 41 percent? And what kind of timeline society 
should have an expectation that that should be dealt with?
    Mr. Jacobs. In the 10-year plan that was published by the 
President's task force last year, we did estimate the 
resources, the expenditures, I should say, that are needed to 
eliminate lead-based paint poisoning from our Nation's housing 
stock.
    That document showed that it would take a total 
expenditure, not necessarily a Federal expenditure, but a total 
expenditure of $230 million a year for the next 10 years. That 
takes into account ongoing housing demolition, ongoing housing 
rehab, and the effect of the regulation for Federally-assisted 
housing.
    That is why Operation LEAP is so important, because we 
think that that will help bridge the gap between the current 
Federal appropriation and where we need to be in terms of total 
expenditures to make our housing stock lead-safe.
    That figure is based on interim controls, which means a 
method of making housing safe and then requiring management of 
lead in an ongoing way.
    Abatement, which is a more permanent corrective measure, is 
more costly. In that report, we estimated what the costs would 
be for abatement of low-income housing, which would be $2.1 
billion per year for 10 years.
    Senator Corzine. We are actually getting a different 
number, at least kicked out of my reading of that report, 
although, whatever the number, $2.1 or the $10 billion that I 
actually have here, what is the amount that has been asked for 
in the budget for 2003, with regard to lead-based paint hazard 
control?
    Mr. Jacobs. The President's request this year is $126 
million, which is an increase from $110 million the previous 
year. If you go back to 1998, 1997, the figure was set at $60 
million. So, basically, the appropriation figure has doubled in 
the last few years.
    The capacity is built. And I have to tell you, one of the 
hardest decisions I make each year is to look at the grant 
applications that we receive each year. Most of them 
demonstrate need, have a good program in place, and have the 
capacity to handle the resources. We have to choose a fraction 
of them to actually receive the funds that are necessary.
    Senator Corzine. And what, in fact, happens to the ones 
that are not?
    Mr. Jacobs. They apply the following year. We encourage 
them to apply, and we try and make the wisest, most targeted 
use of the grant dollars that have been appropriated to us.
    Senator Corzine. This is one of those things where 
sometimes we wonder, or at least have to question our 
priorities, because sometimes--and this is not personal--when 
those elements are left out, we end up paying for it in a whole 
series of other venues because of the kind of implications that 
the lead-based poisoning can bring to bear on our children and 
families and health. I appreciate very much your response.
    Senator Reed. Thank you very much, Senator Corzine. I have 
a few more questions, and if you have additional questions, I 
will recognize you.
    Mr. Jacobs, just a follow-up to Senator Corzine's line of 
questioning. You mentioned the regulations that are promulgated 
with respect to the 1992 Act. I understand that the HUD Single-
Family Mortgage Insurance Program was the only program not 
updated in those regulations. Is there any particular reason 
for that?
    Mr. Jacobs. That is correct. There are regulations for that 
program that have been in place for 15 or 20 years that require 
visual assessment and correction of deteriorated paint and 
clean up, no clearance testing.
    I should note that Multifamily Mortgage Insurance is 
covered by that regulation. A subpart of that rule remains 
reserved for the Single-Family Mortgage Insurance Program. But 
beyond that, I need to get back to you with a more complete 
answer.
    There are some significant concerns about costs, the impact 
on homeownership, and the impact on other secondary mortgage 
institutions such as Fannie Mae and Freddie Mac.
    Senator Reed. Is there a significant incident of lead 
exposure and contamination in those particular units?
    Mr. Jacobs. Well, of course, FHA finances low-income 
housing, for the most part. And certainly, in low-income 
housing, we know that the prevalence of lead-based paint 
hazards is higher. And the likelihood of lead paint in the 
older housing stock is certainly greater. So, clearly, there is 
a potential threat there that needs to be examined and looked 
at.
    Senator Reed. Thank you.
    Dr. Jackson, you indicated in your testimony that there is 
between 500,000 and 750,000 children with elevated blood-lead 
levels. How many of these children can the CDC, together with 
States, effectively track today with the level of resources you 
have? Are we close or are we just getting a mere fraction in 
terms of monitoring, testing, and giving you the information?
    Dr. Jackson. The last time we did the calculation for kids 
over 10, the number came in at about 850,000. But that was in 
1990. Our guess right now is that we are in the 500,000 to 
700,000 range.
    We are really going through a real transition with this 
program where we are--at one point, we wanted to fund every 
single State and every locality and we spread the money very, 
very thinly. That is not going to work.
    There are hot spots and we are pulling back and we are 
going after the areas and using the money that we have as 
effectively as possible, and will use them in the cities and 
urban areas with the oldest housing, with the record of kids, 
and with good, solid management. Putting it into a place that 
does not want to invest its own State or local money, is not 
going to take authority and responsibility for the program and 
have a coalition of housing and enforcement people. It is not 
worth doing.
    And so, honestly, our approach is, here is what we have and 
we are going to apply it in the most effective way possible, 
rather than--I have not really thought about it from the way 
you have asked the question, Senator. I am sorry.
    Senator Reed. But, essentially, your first constraint is 
the resources.
    Dr. Jackson. We do the best we can with the resources we 
have.
    Senator Reed. In that respect or regard, too, your HITS 
program, which is an innovative way to target, given your 
resources, how broadly can you expand this program, or how 
quickly?
    Dr. Jackson. I will be honest, HITS is expensive, in the 
sense that it requires people.
    The good news is you get community engagement, and you have 
residual interest. The one in Chicago got a lot of media and 
political interest. And so, the community became invested in 
this. It had a lot of secondary benefits.
    The other benefit is, if you are in that house looking at 
that child, you might be able to check an immunization record. 
You could look at some cockroach or asthma or other kinds of 
problems at the same time.
    So looking very, very narrowly at lead in this population, 
I think what we are really coming to, and it is what Mr. Jacobs 
deals with a lot, is a healthy homes approach, where lead is 
part of a larger strategy for the homes of the poor.
    Senator Reed. But I think what you suggest, this is an old 
public health model, where a public health nurse walks in the 
door and checks for everything.
    Dr. Jackson. It absolutely is an old model. If you talk to 
the public health nurses of 30 years ago, they say it worked 
great. But it is not cheap.
    Mr. Jacobs. If I might add.
    Senator Reed. Mr. Jacobs, please.
    Mr. Jacobs. One of the things that our rule requires is 
actually a data match between lists of poisoned children that 
are held by local health departments and lists of subsidized 
housing that HUD grant recipients maintain. And so, one of the 
major changes in my view that needs to occur is that we should, 
in addition to tracking children, track houses.
    In all too many cases, there are, ``repeat offenders'' 
where the same house will be responsible for multiple 
poisonings. And in fact, that is how we launched our 
enforcement initiative. We took a look at the cities that had 
the highest numbers of dilapidated, pre-1940 rental stock, and 
combined that with some CDC data, and came up with where we 
should go.
    Senator Reed. You have anticipated a question I had, and I 
think Mr. Sansonetti might comment also. If the child is 
poisoned and then he or she is treated, and then the next 
family moves in and that child is poisoned, and the next, that 
seems to me a pretty good indication that action should be 
taken. Is that a principle that you are following in the 
Justice Department, Mr. Sansonetti?
    Mr. Sansonetti. It certainly is. Our job, of course, is to 
be the backstop to people like investigators at EPA and HUD. 
And it is when they come upon violators that choose to go ahead 
and be obstinate and being unwilling to do what needs to be 
done, that they then come to us and say, well, maybe the person 
wants to answer to a Federal judge rather than do the right 
thing. But as far as deciding when you do something civilly or 
criminally, obviously, if it is a repeat offender, if you have 
a death involved--the magnitude and the number of the case is 
going to help decide whether we put it into the civil or into 
the criminal bailiwick.
    Two other things I would actually follow-up on in regard to 
some of the questions you have asked today, is the fact that 
publicity about what we are talking about today is absolutely 
key.
    One of the reasons that, frankly, as an Assistant Attorney 
General, I was anxious to come to participate today, was 
because this is one of the initiatives that I am pushing.
    Now, admittedly, I had only been there about 155 days. But 
the fact is that this is stuff that we can put into my speeches 
to the different groups, real estate conventions, as part of 
their continuing education as a real estate entity, that they 
realize that this is one of the things that they have to make 
sure happens.
    They could potentially be held responsible for themselves, 
if they are the owners of some of these buildings, we are going 
to start to get the word out.
    We have 4,500 active cases going right now across the board 
in the ENRD.
    It is no accident that I have taken cases like that Nuyen 
case here in Maryland, and the Aneckstein case for our key 
publicity roles. We now actually have a person in our office of 
public affairs assigned to my division to help get the kind of 
publicity out so that we can leverage a conviction like the 
Nuyen case, and the one up in New Hampshire.
    So maybe it was just one conviction in a particular site. 
But if we trumpet it out, as we have in those cases, and it 
ends up in The Wall Street Journal, as well as the local paper, 
then we are getting more bang for our buck because more people 
are saying, whoa, I did not realize that I could go to jail for 
2 years.
    Pay that kind of fine? Maybe we had better make sure that 
our darned pamphlets have been distributed and signed off on.
    So the fact that you are having this hearing today is one 
of the things that attracted me, because this is the kind of 
publicity that we need on this topic.
    Senator Reed. One final general question. A lot of the 
regulatory apparatus is based upon disclosure of lead risks and 
hazards by the landlord. Sometimes that prompts landlords to 
know as little as they can about their property since they are 
held only, I believe, to the standard of what they know about 
the property, which raises a real problem. I wonder if that 
approach is denying us effectively reaching children where 
landlords will deliberately not test their property, or not 
want to know about what is going on. Your experience, Mr. 
Jacobs? Anyone on the panel can comment.
    Mr. Jacobs. You are referring to a potential chilling 
effect for disclosure.
    Senator Reed. Right.
    Mr. Jacobs. That it is better not to know than to know.
    Senator Reed. Is that a real issue out there or this is 
just something hypothetical that we can dismiss?
    Mr. Jacobs. I guess I would answer it this way. By looking 
at what has happened in our project-based Section 8 inventory, 
which is privately-owned, but subsidized.
    In that program, we required risk assessment and an 
inspection and then made a voluntary program available to 
owners to participate if they wished. Now if they wanted to put 
their heads in the sand and not participate, we did not require 
them to use our program to obtain free lead-paint inspections. 
But most of them have, in fact, come in and tried to determine 
where their hazards are and how to best correct them.
    It is more advantageous for a property owner to know 
exactly where their lead-paint hazards are so that they can 
minimize both their liability exposure and their ongoing 
maintenance and rehab activity so that they are property 
targeted. If they do not know, then, of course, the liability 
would increase.
    But you are correct. The existing disclosure rule does not 
require an inspection and in most cases that I am aware of, we 
know that, in fact, people generally check the I-Don't-Know 
box. And in that sense, the real information that a parent 
needs--where is the paint? Where are the hazards?--is not 
provided.
    Senator Reed. Let me just raise one final question because 
a vote has been called, apparently, and I will conclude the 
hearing. But we have heard today that the vast majority of 
exposure to lead is in the home. Medicaid allows States to 
cover the cost of one-time environmental assessments of the 
home. However, I understand that Medicaid will not pay for 
testing the dust, soil, or water as part of this assessment. I 
was, in my early days, when I became familiar with this 
problem, shocked to learn that it is not just the home, it is 
outside in the soil, particularly in low-income neighborhoods. 
And yet, those areas are not tested. Might you comment, Mr. 
King-Shaw?
    Mr. King-Shaw. Yes, and that is a problem. We are limited 
by the fact that we are bound to reimburse testing for human 
specimen only, by Medicaid rule, by policy, by limitation. For 
us to test anything more than that would require a change in 
our authority, which is not present today.
    Senator Reed. Thank you for the response.
    Let me thank all of you for your testimony today and thank 
my colleagues, Senator Allard and Senator Corzine, for 
participating. We appreciate certainly your time and the effort 
you have put into this hearing this afternoon.
    It is apparent from today's testimony, we have a great task 
before us. We need to find the will and the resources to 
eradicate lead hazards that affect hundreds of thousands of 
children, perhaps even millions. We also need to make more 
Americans aware of the dangers of lead poisoning.
    At the same time, though, we have heard about how much 
progress we have made on this issue and what Federal officials 
are doing to continue this progress.
    That is good news, and I look forward to continuing to work 
with you. I would ask, if you have any additional statements, 
to please submit them. And also, if there are additional 
questions, we will provide them to you and ask for your 
response no later than next Monday--10 days from today.
    Thank you very much for your testimony.
    The hearing is adjourned.
    [Whereupon, at 4:05 p.m., the hearing was adjourned.]
    [Prepared statements and response to written questions 
supplied for the record follow:]

                PREPARED STATEMENT OF SENATOR JACK REED

    This hearing is one in a series I hope to have to bring greater 
attention to the terrible problem of lead poisoning in out Nation's 
housing and its effects on children. The hearing is a follow-up to the 
Senate Housing Subcommittee hearing held last year regarding State and 
local responses to lead-based paint poisoning.
    Over a decade ago, the U.S. Department of Health and Human Services 
announced a strategic plan for the elimination of childhood lead 
poisoning because it recognized the detrimental, long-lasting effects 
on children from exposure to lead. The efforts to achieve the long-
established goal of eliminating lead poisoning by the year 2010 has 
stalled and may in fact be moving in the opposite direction.
    Not only are Federal laws not being enforced, such as the 
requirement that all Medicaid eligible children be screened for lead, 
it also appears that there is currently no coordinated action to 
eliminate childhood lead poisoning.
    The previous Administration created a Task Force on Children's 
Environmental Health and Safety Risks. This task force was cochaired by 
the Secretary of the Department of Health and Human Services and the 
Administrator of the EPA and developed a set of recommendations to 
eliminate childhood lead poisoning in the United States as a major 
public health problem by the year 2010.
    Specifically, this comprehensive Government-wide strategy called 
for making 2.3 million homes where children under the age of six live 
lead-safe by controlling lead-paint hazards. It also called for public education programs, strict enforcement of lead-paint regulations as 
well as encouraging early interventions for at-risk children.
    With only 8 years to go until we are to have eliminated childhood 
lead poisoning, it is estimated that nearly one million preschool 
children living in the United States continue to have blood-lead levels 
high enough to impair their ability to think, concentrate and learn.
    Unfortunately, except for the most severely poisoned children, 
there is no medical treatment for this disease. The only effective 
treatment is preventing exposure.
    The Department of Housing and Urban Development estimated in its 
latest national survey that lead still remains in about 39 million 
dwelling units or 40 percent of all U.S. housing.
    Federal efforts to reduce the hazards of lead-based paint poisoning 
began 31 years ago with the enactment of the Lead Paint Poisoning 
Prevention Act. This Act required the Secretary of HUD to establish and 
implement procedures to eliminate lead-hazards from public housing.
    In 1992, Title X of the Housing and Community Development Act 
authorized major changes in Federal law in the control of lead-based 
paint hazards and the reduction of lead exposure.
    Title X defined ``hazard'' in such a way that it included 
deteriorating lead-paint, and the lead contaminated dust and soil that 
the lead-paint generates. It also mandated the creation of an 
infrastructure that would help correct lead-paint hazards in all of our 
Nation's housing.
    In particular, Title X required coordinated action between several 
Federal agencies regarding lead poisoning, including the Department of 
Housing and Urban Development (HUD), the Environmental Protection 
Agency (EPA) and the Centers for Disease Control and Prevention (CDC).
    While we have made progress in dramatically reducing the number of 
children with elevated blood levels, significant barriers and obstacles 
to the elimination of this environmental health hazard remain.

 Why are only 20 percent of children enrolled in Medicaid being 
    screened for lead poisoning, when Federal law requires that all 
    children be tested?
 If a child tests positive for high levels of lead in their 
    blood, why aren't their homes being reported and screened for lead?
 Why hasn't the Environmental Protection Agency promulgated 
    regulations on the safe renovation and remodeling of housing 
    containing lead-based paint?
 How many new cases has the Department of Justice filed against 
    landlords who are violating laws designed to protect tenants from 
    lead poisoning?
 Why is HUD's single family mortgage insurance program the only 
    program not to be updated in HUD's new lead-paint regulations for 
    assisted housing?

    We expect today's hearing to provide some of the answers to these 
questions. We will get an overview of what a number of Federal 
agencies--HUD, EPA, CDC, DOJ, and CMS--are currently doing to help make 
housing lead-safe for children; how well these agencies are 
coordinating with one another; and what additional tools each agency 
needs to achieve the national goal of eliminating lead poisoning by 
2010.
    This hearing is only the second in a series of Senate Housing 
Subcommittee hearings on lead-based paint-poisoning. It is my hope that 
these hearings will help shine a light on this terrible problem, 
energize the Federal Government into playing a greater role, and 
improve local, State and Federal partnerships to eliminate lead-based 
paint-poisoning by 2010.
    Federal taxpayers and low-income children and families are paying 
the price for these deficiencies in terms of added costs for special 
education and the long-term health and developmental problems in lead 
exposed children.
    More needs to be done. No child should have to live with the 
consequences of this preventable disease.

Senator Jack Reed's Efforts to End Lead Poisoning
    Senator Reed has worked in Congress to increase funding to combat 
lead poisoning and to ensure that children are screened for lead in 
their blood before entering kindergarten. Senator Reed secured a 25 
percent increase in 2001, and a 10 percent increase in 2002 in the 
Department of Housing and Urban Development (HUD) budget to remove 
lead-based paint, educate families about the dangers of lead, help 
cities comply with new Federal lead-safety regulations, test low-income 
housing units for the presence of lead and train inspectors and workers 
to identify lead contamination in housing.
    He has sponsored legislation to require all children covered under 
Federal health programs to be screened and treated for lead poisoning. 
Reed's provision was included in the Children's Health Act of 2000, 
which was signed into law in October 2000. It also authorizes the 
Centers for Disease Control & Prevention to issue recommendations to 
ensure uniform reporting requirements for blood-lead levels at State 
laboratories and to improve data collection on the number of children 
screened for lead poisoning annually.
    He introduced legislation to give the Federal Government the 
authority to sue the lead-paint industry to recover costs related to 
the lead poisoning of children and the removal of lead-paint from 
homes.
    In October, 1999, Mrs. Tipper Gore, the national spokeswoman for 
the Campaign for a Lead-Safe America, dedicated a lead-safety center in 
the Elmwood section of Providence, Rhode Island in recognition of 
Senator Reed's national leadership to protect children from the dangers 
of lead poisoning.
    The Reed Center, which is run by the Greater Elmwood Neighborhood 
Services (GENS) and the Health Education Leadership for Providence 
(HELP), is for those families who are dealing with the legacy of lead. 
Through counseling and treatment, the Center had helped more than over 
500 families cope with the effects of lead poisoning since October 
1998.
    For the past 3 years Senator Reed has successfully sponsored a 
resolution designating a week in October as ``National Childhood Lead-
Poisoning Prevention Week,''
    Senator Reed has also held Senate hearings in Rhode Island and 
Maine with Senator Susan Collins (R-ME) to highlight the important 
successful approaches being undertaken by State organizations, such as 
the Greater Elmwood Neighborhood Services (GENS), the Health and 
Education Leadership for Providence (HELP) and the Childhood Lead 
Action Project.
    On discovering that the Rhode Island Housing Authority was not 
implementing Federal regulations regarding the elimination of lead-
hazards in Federally subsidized housing (Section 8 Housing), Senator 
Reed secured an agreement between the Federal Government and the 
Housing Authority to ensure greater oversight and coordination of the 
Housing Authorities efforts.

                               ----------
               PREPARED STATEMENT OF SENATOR WAYNE ALLARD

    I would like to thank Chairman Reed for holding this hearing on the 
hazards of lead-based paint. Childhood lead poisoning is the most 
common environmental disease of young children. It affects nearly every 
system in the body and even low 
levels of contamination can cause debilitating damage to children, 
impairing intelligence, muscle control, hearing, and emotional 
development.
    The lead-paint in older housing and contaminated dust and soil it 
generates is the most common source of lead exposure for children. In 
the United States today, nearly one million children ages 1 to 5 have 
elevated blood-lead levels.
    According to HUD's National Survey of Lead and Allergens in 
Housing, an estimated 40 percent of all homes have lead-based paint 
somewhere in the building, whether it be on the inside or outside of 
the structure. Twenty-six percent of all homes have significant lead-
based paint hazards, and of the 16.4 million homes with one or more 
children under the age of 6, 27 percent have significant lead-based 
paint hazards.
    All of this is the bad news, but the good news is that lead 
poisoning is preventable and that is why we are convening here today. I 
look forward to hearing about what each of the five Federal agencies is 
doing to help in this prevention effort.
    I thank the Chairman for holding this hearing and giving us the 
opportunity to learn more about the issue, what is currently being 
done, and what more can be done with regard to lead-based paint 
hazards.
    Thank you, Mr. Chairman.

                               ----------
              PREPARED STATEMENT OF SENATOR JON S. CORZINE

    Mr. Chairman, I want to commend you for holding this important 
follow-up hearing on the Federal responses to lead-based paint 
poisoning. This is an issue of great concern to me and to my State, 
which is struggling to find the resources it needs to fund lead-paint 
abatement programs and ensure access to early detection of childhood 
lead poisoning.
    This is a public health problem of enormous consequence for our 
cities, States, and our Nation. At least one million children 
nationwide are victims of lead poisoning. These children have reduced 
IQ, hearing, growth, behavioral problems, and impaired nerve function. 
Many of them suffer from severe brain damage.
    It is estimated that as many as two million homes in New Jersey 
that were built before 1978 contain toxic lead. Nine out of every 10 
houses in the city of Newark are tainted with the poison. Some 
estimates show that up to 50 percent of Newark's children may be 
affected by lead poisoning. Because screening efforts have been slow, 
only 4,000 children in the city have been identified as having elevated 
blood-lead levels. As a rule, these children come from low-income 
minority households.
    While lead-based paint poisoning is a very local problem, it is 
also a Federal problem. States and localities are unable to bear the 
costs of lead abatement, which amount to about $15,000 per unit. 
Funding for the Federal Lead-Based Paint Program must be dramatically 
increased if we are to adequately remove the paint that continues to 
plague millions of low-income homes in this country.
    Despite the fact that 80 percent of children with elevated blood-
lead levels receive Medicaid assistance, a 1999 GAO report found that 
only 20 percent of children receiving Medicaid benefits had been 
screened for lead poisoning. This is a national disgrace. In 1989, 
Congress required that all children receiving Medicaid be screened for 
blood-lead levels, however, enforcement of this law has been minimal. I 
am deeply troubled by recent comments made by CMS staff that this 
Administration finds the Medicaid childhood lead screening requirement 
overly burdensome and costly for States. Unfortunately, the learning 
disabilities and public health costs associated with lead poisoning are 
much greater.
    We must not only ensure that children are screened early, but also 
that they are screened through age 6. The Centers for Medicare and 
Medicaid currently only requires that children be screened through age 
2, despite the fact that lead poisoning poses a clear danger to 
children up to age 6. Additionally, children participating in the Head 
Start Program should be screened for lead poisoning. While children who 
participate in the Head Start Program are screened for many 
developmental disorders, they are not screened for the blood-lead 
levels that so often cause these 
disabilities. Mr. Chairman, I know you have introduced legislation, 
which I have 
cosponsored, to make screenings available through the Head Start 
Program. I hope to see passage of this bill in the near future.
    The public health and societal costs of this problem are enormous. 
This Administration must affirm its commitment to enforcing lead 
disclosure laws, Medicaid screening laws, and lead abatement programs. 
I am pleased that the President has made ending lead-based paint 
poisoning in the next 10 years a priority and I look forward to working 
with the Administration toward that end.

                               ----------
             PREPARED STATEMENT OF SENATOR DEBBIE STABENOW

    Mr. Chairman, thank you for calling this second hearing on lead-
based paint poisoning. This is an incredibly important topic and I am 
glad that today we are examining the Federal Government's role in 
eliminating this problem.
    Lead-based paint poisoning remains a serious problem for too many 
children. And, we in Congress have an obligation to increase our 
efforts to combat this problem. Lead-based paint poisoning can be 
abated and even eliminated if we are willing to pay the price and 
implement the necessary measures. This is precisely why I was happy to 
join the Chairman and several other colleagues last month in writing to 
Senate appropriators, urging them to provide $200 million for the 
Department of Housing and Urban Development's lead safety grant program 
and for $110 million for the Primary Prevention Initiative.
    I worry a great deal about lead-based paint poisoning because I 
know it is a serious problem for many children, but it is particularly 
a problem in my home State of Michigan. Indeed, according to the 
Alliance to End Childhood Lead Poisoning, Detroit ranks third in number 
of cases of children identified as having severe lead poisoning. And 
last year, the Detroit News reported that children in several Detroit 
neighborhoods had lead levels that were 10 times the national average. 
This is truly outrageous and disturbing.
    The Federal Government's responsibility in regard to this problem 
is clear and I want us to do more. To help address this problem back in 
Michigan, I am already working to obtain critical Federal funding for 
the CLEARCorps program in Detroit and in Grand Rapids.
    As the Chairman knows, CLEARCorps is an innovative nation-wide 
network of public-private partnerships that has a proven record of 
offering cost-effective methods of fighting childhood lead poisoning.
    Mr. Chairman, I look forward to hearing from our witnesses today 
and, again, I thank you for your leadership on this. The day when no 
child is at risk for lead-based poisoning is conceivable and I want to 
work with you so that we make that day happen sooner rather than later.

                               ----------
              PREPARED STATEMENT OF DAVID E. JACOBS, Ph.D.
       Director, Office of Healthy Homes and Lead Hazard Control
            U.S. Department of Housing and Urban Development
                              June 5, 2002

    Thank you for the opportunity to discuss HUD's activities in the 
area of childhood lead poisoning prevention. The evidence shows that 
while the Nation has made much progress, much remains to be done to 
meet the goal of eliminating the disease by 2010.
    I am the Director of the HUD Office of Healthy Homes and Lead 
Hazard Control. Before joining HUD 6 years ago, I was Deputy Director 
of the National Center for Lead-Safe Housing and a scientist on the 
faculty at the Georgia Institute of Technology, where I conducted 
research on residential lead hazard detection and control. I am also a 
board-certified industrial hygienist.
    HUD Secretary Mel Martinez has made childhood lead poisoning 
prevention one of the priorities of his administration. As a result of 
this commitment, we have trained over 28,000 housing rehab and 
maintenance workers and others in the past year alone in lead-safe work 
practices. We have increased HUD's lead hazard control budget by 10 
percent for fiscal year 2002 and the President's budget proposal for 
fiscal year 2003 increases it further still, from $110 million to $126 
million. The Secretary has also increased our Office's staffing to 
improve our grant delivery, 
enforcement, public education, and research efforts.
    The most current nationwide estimates from the Centers for Disease 
Control and Prevention (CDC) show that 890,000 children had blood-lead 
levels above the CDC level of concern during the time of the survey 
(1991-1994). That study also showed that 21 percent of African-American 
children living in older housing where lead-based paint is most 
prevalent were poisoned, compared to 4.4 percent for the general 
population. In December of 2000, the CDC provided more recent data 
showing that while some counties had prevalence rates as high as 27 
percent, the average blood-lead level in young children declined by 25 
percent from 1996-1999 to 1.9 micrograms per deciliter, suggesting 
our efforts to make U.S. housing lead-safe are successful.
    The reason for this success is that the Nation took action. Lead 
exposures from food canning, gasoline, and new paint were eliminated. 
Lead in air emissions, occupational exposures and water all were 
controlled and older housing with lead-paint is continually being 
rehabilitated, abated, or demolished. Studies of the numerous, but 
often subtle, harmful effects of lead were completed and a consensus 
emerged. All of these actions have caused average blood-lead levels to 
decline by over 80 percent since the 1980's, an achievement that ranks 
as one the Nation's most successful public health stories.
    Nevertheless, the evidence is clear that the major high dose source 
for most children today is existing lead-based paint in older housing 
and the contaminated dust and soil it generates. More must be done to 
prevent hundreds of thousands of additional children from being 
poisoned in the decades to come. HUD's new survey of lead-based paint 
in housing shows that the estimated number of homes with lead-paint 
declined from 64 million in 1990 to 38 million in 2000. Of the 38 
million units with lead-paint, 25 million have lead hazards. Of those 
25 million, 5.6 million house children under the age of 6, 1.6 million 
of those units house low-income families with children under 6, the 
population most at-risk of elevated blood-lead levels. Forty-one 
percent of low-income housing has lead-paint hazards, compared to 18 
percent of middle- and upper-income housing. HUD expects to repeat the 
survey of housing with lead hazards in 2004, which will help better 
determine long-term trends of lead hazard reduction.
    Importantly, Government-supported housing, which is almost all low-
income housing, has a prevalence rate of 17 percent, about the same as 
the middle- and upper-income housing. Therefore, from a lead-safety 
perspective, Government-supported housing is also the safest housing, 
the strongest indication yet that the Federal standards are effective. 
The data also show that the problem is most severe in privately-owned 
low-income housing that is or will be occupied by families with young 
children. These are precisely the houses that are targeted by HUD's 
Lead Hazard Control Grant Program.
    HUD has worked closely with other Federal agencies to protect 
children from lead poisoning. We must work more closely with other 
agencies to match families with young children and houses that have 
been made lead-safe through our various programs. We should find ways 
to get this information to families who need it most, such as Medicaid-
eligible families. One option could be to make more information about 
HUD lead hazard control programs available to State Medicaid agencies 
through Centers for Medicare & Medicaid Services (CMS), CDC, and other 
components of the Department of Health and Human Services (HHS). When 
CDC conducted its High Intensity Targeted Screening effort in Chicago 
recently, HUD was there to provide resources needed to eliminate lead-
based paint hazards for children who had not been previously identified 
as being at risk.
    After a transition period, HUD's new lead-based paint regulation 
for Federally-assisted housing is now in effect across the country. 
Federally-assisted housing now includes modern, more effective, and 
scientifically proven hazard identification and control methods to 
ensure that it is safe for children. This regulation brings lead hazard 
control procedures into routine housing finance, maintenance, and rehab 
systems and therefore represents a change from the way the Nation 
approached the problem in the past, which was largely reactive and 
inadequate. In short, we take action before a child is poisoned, 
instead of only acting after the damage has been done. HUD's procedures 
for Federally-assisted housing provide a template for promoting lead 
safety in other housing with lead-paint hazards. Furthermore, the 
capacity we have built to implement lead-safe work practices among 
painters, remodelers, renovators and maintenance personnel can be used 
more broadly, because many contractors often work in both assisted and 
nonassisted housing.
    In addition to all this, we have:

 Developed a 10-year strategy to eliminate childhood lead-paint 
    poisoning, which was published by the President's Task Force (this 
    marked the first time that Federal agencies developed a coordinated 
    approach and documented the resources needed).
 Linked lead safety to other children's health hazards that may 
    be caused by underlying housing conditions through HUD's Healthy 
    Homes Initiative.
 Created an effective lead hazard control grant program to 
    eliminate lead-based paint hazards in privately-owned low-income 
    dwellings where hazards are greatest. Today, HUD's program is 
    active in over 200 jurisdictions across the country.
 Together with State and local law enforcement, health and 
    housing departments, the Department of Justice and EPA, enforced 
    the lead-based paint disclosure regulation (so far, we have brought 
    cases that have resulted in compliance and lead-paint abatement in 
    over 158,000 high-risk dwelling units, as well as two criminal 
    convictions against landlords who failed to comply).
 Conducted the Nation's largest study of modern lead hazard 
    control techniques to determine the effectiveness of the HUD grant 
    program (the results show that children who live in units where 
    hazards have been eliminated have a 25 percent lower blood-lead 
    level and their homes have a sustained 50-88 percent decline in 
    dust-lead levels).
 Conducted research to reduce the cost and increase the 
    effectiveness of hazard identification and control technologies.
 Completed the inspection and risk assessment of tens of 
    thousands of units receiving HUD Section 8 project-based subsidies.
 Paid for clearance testing in public housing and in HUD-funded 
    rehab programs covered by HUD's lead-safe housing rule.
 Performed public education and outreach services through 
    private sector organizations such as Sears.
 Has been recognized by the Office of Management and Budget as 
    an ``effective'' program.
 Published technical guidelines, in the form of a 500 page 
    compendium of 
    best practices that is regarded by practitioners in the field as 
    state of the art and 
    widely referenced in Federal, State, and local regulations.

    Another opportunity for collaboration is between HUD and the 
Environmental Protection Agency (EPA). HUD and EPA have worked together 
to target our regulations so that abatement contractors are used for 
the most dangerous jobs, not routine housing rehab, and so that housing 
rehab workers get the training they need to do their jobs safely. For 
example, EPA developed a curriculum for lead-safe renovation work 
practices, which HUD adopted for use in assisted housing programs.
    HUD and HHS already collaborate on the National Health and 
Nutrition Examination Survey (NHANES), where HHS pays for analysis of 
children's blood-lead samples and HUD pays for analysis of dust-lead 
samples in children's homes. It is possible that this partnership could 
be expanded to permit NHANES to characterize the extent of lead hazards 
in the Nation's housing.
    HUD has also coordinated with the Department of Energy's 
weatherization programs. Weatherization measures are intended to make 
homes more energy efficient and may include window replacement, door 
repair, and restoration of deteriorated walls. Unfortunately, such 
measures may also involve disturbing lead-based paint. If contaminated 
dust and paint chips are not properly controlled and cleaned up, 
weatherization may inadvertently increase children's exposures. When 
weatherization is performed as suggested in such weatherization 
programs, it can eliminate lead-based paint hazards--a win-win 
opportunity. Many HUD grantees leverage lead hazard control and rehab 
funding with DOE weatherization funding. For example, replacement of 
windows is both a key weatherization practice and an effective lead 
hazard control method. While Title X of the 1992 Housing and Community 
Development Act does not cover DOE weatherization programs, we believe 
weatherization work practices must be consistent with lead-safe work 
practices to ensure children are protected in homes undergoing 
weatherization.
    I would like to close by discussing the Secretary's new effort to 
increase the involvement of the private sector in lead poisoning 
prevention. HUD will soon release a Notice of Funding Availability for 
Operation LEAP (Lead Elimination Action Program). Grants will be 
awarded to entities that can demonstrate they can leverage additional 
funding and resources for local lead hazard control programs. Congress 
appropriated $6.5 million for this new effort for fiscal year 2002. We 
are hopeful the private sector will respond to this opportunity to help 
solve this problem.
    Finally, let me recognize Senator Jack Reed for his resolve and 
commitment to this important issue.

                               END NOTES

    1. Centers for Disease Control and Prevention, ``Update: Blood Lead 
Levels--United States 1991-1994,'' Morbidity and Mortality Weekly 
Report, U.S. Department of Health and Human Services/Public Health 
Service, Vol. 46, No. 7, February 21, 1997, pp. 141-146 and erratum in 
Vol. 46, No. 26, p. 607, July 4, 1997.
    2. Centers for Disease Control and Prevention, Blood lead levels in 
young children--United States and Selected States, 1996-1999, Morbidity 
and Mortality Weekly Report 49(50): 1133-1137, December 22, 2000.
    3. Agency for Toxic Substances and Disease Registry, The Nature and 
Extent of Childhood Lead Poisoning in the United States: A Report to 
Congress, July 1988.
    4. Brody et al., Blood lead levels in the U.S. Population: Phase 1 
of the Third National Health and Nutrition Examination Survey, 1988 to 
1991, Journal of the American Medical Association 272(4): 277-283, July 
27, 1994; and Pirkle et al., The decline in blood-lead levels in the 
United States, Journal of the American Medical Association 272(4): 284-
291, July 27, 1994.
    5. National Academy of Sciences. Measuring Lead Exposure in 
Infants, Children, and Other Sensitive Populations, Report of the 
Committee on Measuring Lead in Critical Populations, Board on 
Environmental Studies and Toxicology, Commission on Life Sciences, 
National Academy of Sciences. Washington, DC: National Academy Press, 
1993.
    6. Jacobs DE. Lead-based paint as a major source of childhood lead-
poisoning: A review of the evidence. In: Lead in Paint, Soil and Dust: 
Health Risks, Exposure Studies, Control Measures and Quality Assurance 
(Beard ME and Iske SDA, eds). Philadelphia: ASTM STP 1226, American 
Society for Testing and Materials, 1995; 175-187.
    7. McElvaine MD, DeUngria EG, Matte TD, Copley CG, Binder S. 
Prevalence of radiographic evidence of paint chip ingestion among 
children with moderate to severe lead poisoning, St. Louis, Missouri, 
1989-1990, Pediatrics 89:740-742 (1992).
    8. Clark CS, Bornschein R, Succop P, Roda S, Peace B. Urban lead 
exposures of children in Cincinnati, Ohio, Journal of Chemical 
Speciation and Bioavailability, 3(3/4):163-171.
    9. Jacobs et al., The Prevalence of Lead-Based Paint Hazards in 
U.S. Housing, accepted for publication in Environmental Health 
Perspectives, 2002. Also see HUD, National Survey of Lead and Allergens 
in Housing, 2001 (available at www.hud.gov/offices/lead).
    10. President's Task Force on Environmental Health Risks and Safety 
Risks to Children. Eliminating Childhood Lead Poisoning: A Federal 
Strategy Targeting Lead-Based Paint Hazards. Washington DC: U.S. 
Department of Housing and Urban Development and U.S. Environmental 
Protection Agency, February 2000.
    11. Galke W, Clark S, Wilson J, Jacobs D, Succop P, Dixon S, 
Bornschein B, McLaine P, Chen M. Evaluation of the HUD lead hazard 
control grant program: early overall findings. Env Res 86A:149-156 
(July 2001).
    12. Guidelines for the Evaluation and Control of Lead-Based Paint 
Hazards in Housing. HUD 1539-LBP, Washington, DC: U.S. Department of 
Housing and Urban Development, 1997.

                               ----------
               PREPARED STATEMENT OF THOMAS L. SANSONETTI
                       Assistant Attorney General
               Environment and Natural Resources Division
                       U.S. Department of Justice
                              June 5, 2002

    Chairman Sarbanes, Senator Reed, and Members of the Subcommittee, I 
am pleased to be here today, along with my colleagues on this panel. I 
would particularly like to thank Senator Reed for his invitation to 
discuss what the Environment and Natural Resources Division of the 
Department of Justice is doing to make housing in America lead-safe. 
This hearing provides a wonderful opportunity to educate the public 
about the Federal Government's efforts to protect America's most 
important resource, its children, from the evil of lead-based paint 
poisoning.
    In my testimony today, I will focus primarily on the U.S. 
Department of Justice's enforcement efforts in connection with the 
Residential Lead-Based Paint Hazard Reduction Act. I will give some 
background on the genesis of the Act and the enforcement initiative 
developed by our colleagues and clients at the Department of Housing 
and Urban Development (HUD) and the U.S. Environmental Protection 
Agency (EPA), talk about our role in that initiative, and briefly 
discuss a few success stories from the last year in both the civil and 
the criminal enforcement context. I will also touch upon the work of my 
Division in reaching out to the U.S. Attorneys Offices and State and 
local enforcement agencies to help them to be more effective in their 
lead-paint enforcement efforts. I would also be happy to answer any 
questions that the Subcommittee may have about our efforts in this 
important area.

The Federal Residential Lead-Based Paint Hazard Reduction Act of 1992
    Lead poisoning is a significant health risk for young children--it 
can impair a child's central nervous system, kidneys, and bone marrow 
and, at high levels, can cause coma, convulsions, and death. Of course, 
ingesting lead is not good for anyone, but children under 6 years of 
age are at the greatest risk of lead poisoning. This is true for two 
reasons. First, humans are very vulnerable to the effects of lead 
during these formative years, when lead in the bloodstream interferes 
with and retards normal development. Second, as any parent knows, small 
children will put almost anything in their mouths, including paint 
chips, dust and soil containing lead, regardless of how many times you 
tell them not to do it. In fact, lead-contaminated dust generated from 
deteriorated lead-based paint in housing is the single largest source 
of lead poisoning. Lead poisoning is especially acute among low-income 
and minority children living in older housing.
    This public health problem was the genesis of the Federal 
Residential Lead-Based Paint Hazard Reduction Act, 42 U.S.C. 
Sec. 4852d, which requires the sellers, owners, and managers of 
residential buildings built before 1978 (the year that lead was banned 
from residential paint) to warn prospective buyers and tenants about 
the likely (and known, if any) presence of lead-based paint and lead in 
dust or soil on the property. It also requires landlords to give 
tenants an EPA pamphlet about how to minimize the dangers to children, 
and directs them to document their compliance with the law by keeping 
tenants' signatures on file, using a standard disclosure form. 
Regulations implementing the statute are located at 24 C.F.R. part 35 
and 40 C.F.R. Sec. 745.100 et seq.
    With regard to civil enforcement actions, the Act authorizes EPA 
and HUD to assess an administrative civil penalty in the maximum amount 
of $10,000 for each violation. (For violations occurring after January 
31, 1997, this amount has been adjusted to $11,000 per violation under 
the Civil Monetary Penalty Inflation Adjustment Rule.) Although the Act 
provides no authority for judicial civil penalties, it does authorize 
injunctive relief for violations of the Act.
    With regard to criminal enforcement, the Act states that failure to 
comply with the notification requirements is a prohibited act under the 
Toxic Substance Control Act (TSCA) Section 309 (15 U.S.C. Sec. 2689). 
The criminal enforcement provision of TSCA, in turn, provides for a 
criminal fine up to $25,000 for each day of violation and/or a term of 
imprisonment up to 1 year. 15 U.S.C. Sec. 2615(b). As modified under 
the Alternative Fines Act, the maximum criminal fine for this Class A 
Misdemeanor is $100,000 for an individual, 18 U.S.C. Sec. 3571(b)(5) 
and $200,000 for an organization, 18 U.S.C. Sec. 3571(c)(5), per count, 
or the greater of twice the gross gain or loss. 18 U.S.C. Sec. 3571(d).

Lead-Based Paint Enforcement Initiative
    Strong and fair enforcement of the law is necessary to ensure that 
legal goals become practical realities. It is also important that law-
abiding businesses have a level economic playing field on which to 
compete, and that those who fail to comply with the law know they will 
be penalized. In the case of the Lead Hazard Reduction Act, the 
Department of Housing and Urban Development embarked on a civil 
enforcement initiative to ensure compliance with the Act's requirements 
after its effective date in 1996. HUD focused its enforcement actions 
on four major cities--Los Angeles, Chicago, New York, and the District 
of Columbia--and proceeded by targeting large management companies 
responsible for buildings which were covered by the Act and had 
multiple incidents of lead-poisoned children. Among other investigative 
methods, it contacted local health departments and asked them to 
provide the Department with a list of addresses of properties where 
children had been poisoned. It then zeroed in on sites where multiple 
lead-poisoned children appear in a single building or a single owner or 
management company is associated with multiple poisoned children in 
several buildings. EPA also has a lead coordinator in each of its 10 
regions responsible for Lead Hazard Reduction Act enforcement.
    This simple but effective strategy helped the agencies quickly 
identify those companies and individuals who were responsible for some 
of the biggest lead-paint related problems. The agencies could then 
focus their investigative resources on cases that would give the 
biggest bang for the buck, both in terms of the number of housing units 
at issue and in terms of getting the word out about the need to comply 
with the law. Based on this footwork, HUD and EPA began filing a series 
of administrative enforcement actions against violators of the Act.
    Before I go on to talk about our role in this initiative, I would 
like to credit my colleagues and the hard-working people at HUD and EPA 
that have made this initiative such a success. They have done a 
remarkable job in developing investigative strategies and putting in 
the many hours it takes to turn a good plan into great results. One of 
the things Senator Reed asked me to address was how DOJ can interact 
more efficiently with other agencies to eliminate lead-based paint 
poisoning in children, and I am happy to tell you that we are already 
working very well with them to achieve this important goal. Thanks to 
their efforts, and also the efforts of the good people in the U.S. 
Attorneys Offices, the Federal Bureau of Investigation, and the State 
and local agencies responsible for this issue, I have some major 
success stories to tell you on the judicial front.

The Department of Justice's Role in the Initiative
Civil Judicial Enforcement
    And the judicial front is where we at DOJ come in. One way of 
thinking of our role in this initiative is that we provide a backstop 
and a big stick to the agencies. For example, when HUD has confronted a 
violator, but the violator is choosing to be obstinate and unwilling to 
do what needs to be done to make amends for the violations, HUD has the 
option of telling that person that it will refer the case to us and he 
can then answer to a Federal judge instead.
    Also, some cases call out for more than just administrative 
enforcement for a variety of reasons, for example magnitude and 
seriousness of violations, the type of relief that the agencies want to 
obtain from the violators, or the need to get the word out to a broader 
audience about the problem and the need to comply with the law. In 
these cases, the agencies come to us and ask us to pursue actions in 
court.
    We have pursued several cases judicially, beginning with the first 
ones that the Division and HUD filed here in the District in 1999. 
These first actions filed in the U.S. District Court for the District 
of Columbia included four settlements totaling more than $1 million 
worth of lead-paint abatement in close to 4,000 dwelling units, and 
$259,000 in fines and other commitments.
    Our most recent success came last October, when the DOJ, HUD, and 
EPA announced settlements in cases against three landlords in Chicago 
for failure to warn their tenants that their homes may contain lead-
based paint hazards. The three companies in question controlled nearly 
10,000 apartments in Chicago and Cincinnati, and they agreed to test 
for and cleanup any lead-based paint found in their properties, and 
have also paid $90,000 in penalties. One of the companies also agreed 
to pay $100,000 to Chicago's Health Department as part of a child 
health improvement project, and the other two agreed to give $77,000 to 
a community-based health center to provide free blood-lead testing for 
children living in Chicago and South Chicago. These settlements will 
not only get these companies back into compliance with the law, but 
will also provide benefits to the community that would not otherwise 
have been available.
    At the same time, HUD also announced settlements in four 
administrative cases against landlords in New York City and Los Angeles 
that own and manage approximately 6,500 units. The landlords in the 
administrative cases agreed to pay $61,000 in penalties and to test for 
lead-based paint in their properties and cleanup any lead-based paint 
that is found.
    Taken together, these and the many other judicial and 
administrative actions that we have brought demonstrate that this 
enforcement strategy is working--we are getting thousands of units 
cleaned up and the word is getting out to management companies and 
landlords across the country that we are serious about making sure they 
comply with the disclosure requirements. And we have more civil cases 
in the pipeline across the country, from California to Senator Jack 
Reed's home State of Rhode Island.
    Another group that I want to be sure to credit is the U.S. 
Attorneys Offices. To leverage our resources and enhance our 
effectiveness, the Division has forged partnerships with U.S. 
Attorneys' Offices around the Nation and provided them with materials 
and training so they can be more effective in bringing their own lead-
paint cases. They now carry out much of the enforcement of the lead 
rules, which encompasses working with HUD and EPA to investigate 
violations, conducting file inspections to determine compliance with 
the law, and leading the negotiations with violators. In addition to 
the training and materials we provide them, the Division's role in 
cases where the USAO is providing the lead is to assist in drafting the 
settlement document, developing the scope of injunctive relief, and 
determining an appropriate penalty. In doing so, we help to maintain a 
consistent and fair remedial 
approach to lead disclosure cases nationwide.
    We also work with State Attorneys General and other State and the 
local officials across the Nation to increase cooperation among local, 
State, and Federal lead 
poisoning enforcement agencies. The State and local people are 
essential players in this enforcement effort--in fact, our cases often 
get started when we receive reports of elevated blood levels of lead 
from a local health department. Working with the States also gives us 
the advantage of being able to use State and local laws, such as 
Maryland's, which may be more protective than Federal law.

Criminal Prosecutions
    The U.S. Attorneys Offices and the State and local enforcement 
agencies deserve credit in the criminal as well as the civil 
enforcement context. There have been some especially egregious cases 
which have warranted criminal prosecutions. The U.S. Attorneys Offices 
in Maryland and New Hampshire, working with the Justice Department's 
Environmental Crimes Section, have brought the first two criminal 
cases. Their good work has been aided by special agents with HUD's 
Office of the Inspector General, the EPA--Criminal Investigations 
Division, and the FBI, and by others at HUD and EPA. In fact, the 
Division will be presenting them with certificates of commendation 
later this month.
    Consider, for example, the case of David D. Nuyen, a Washington-
area landlord, who owned and managed 15 low-income rental properties in 
the District of Columbia and Maryland. HUD's Office of General Counsel 
contacted Nuyen in September 1998 as part of the civil enforcement 
initiative because his name appeared on a list of landlords with the 
most housing code violations and a list of landlords with multiple 
cases of lead-poisoned children. When first contacted, Nuyen did not 
have any of the required lead-paint disclosure forms, but 2 months 
later, he presented the Agency with lead-paint forms.
    The problem with the forms that he presented to HUD was that they 
were falsified, forged, and backdated. They made it appear that Nuyen 
had given tenants the required hazard warnings when in fact he hadn't, 
even in those instances where he had previously received notices of 
violation from the District of Columbia that an apartment was found to 
have dangerous levels of lead. Moreover, Nuyen was 
familiar with the requirements of the law because he had attended 
classes on the Lead-Based Paint Hazard Reduction Act in 1997 and 1998 
as part of his continuing education requirement for being a licensed 
real estate broker.
    Nuyen's criminal conduct did not stop with the submission of false 
records to HUD. For example, during the course of the criminal 
investigation, Nuyen lied at a meeting with civil enforcement officials 
from HUD and the Department of Justice, he lied to Federal agents, he 
made his tenants sign affidavits under the penalties of perjury falsely 
saying that they had received the lead-paint disclosure forms, and he 
provided false testimony to a Federal Grand Jury on two separate 
occasions.
    Nuyen's outrageous behavior made his case an appropriate one for 
the first criminal prosecution involving the Lead Hazard Reduction Act. 
His conviction last July in Greenbelt, Maryland, for obstruction of 
justice, false statements, and the Lead Hazard Reduction Act, earned 
him a 2-year prison sentence and a $50,000 criminal fine. Under the 
terms of a plea agreement, Nuyen's sentence also required him to 
provide all tenants with new notices about lead-paint assessments 
performed by an independent contractor approved by the Government.
    Another criminal case, United States v. James T. Aneckstein and JTA 
Real Estate Brokerage and Property Management, Inc. (D-NH), culminated 
in March in New Hampshire. This prosecution began with the tragic death 
2 years ago of Sunday Abek, a 2-year-old girl who died of lead 
poisoning while residing in a rental apartment managed by Aneckstein, 
the owner of JTA Real Estate Brokerage and Property Management, Inc. 
(``JTA''). Shortly after the City of Manchester Health Department and 
New Hampshire Department of Health and Human Services announced that 
Sunday's fatal lead poisoning was most likely caused by exposure to 
lead-paint in the apartment in Manchester, New Hampshire, EPA officials 
visited JTA's office to determine whether Aneckstein and JTA had 
complied with the Lead Hazard Reduction Act. Aneckstein presented EPA 
with forged, backdated, and otherwise falsified lead-paint disclosure 
forms that falsely certified that Sunday's mother and other tenants in 
her building had been given the required lead-paint warnings. 
Aneckstein forged the tenants' signatures by reproducing the tenant's 
real signatures from their leases and transposing them onto the lead 
forms in an attempt to conceal his violations of the lead hazard 
disclosure requirements. Aneckstein signed an affidavit falsely 
swearing that all of the documents he provided to EPA were true and 
accurate. When the same information was sought by a Federal grand jury, 
Aneckstein and JTA again submitted false, forged, and backdated 
documents.
    In March of this year, Aneckstein was sentenced in Federal district 
court in Concord, New Hampshire, to 15 months incarceration and a 
$40,000 criminal fine. Again, prosecutors required Aneckstein and his 
company, as part of a plea agreement, to perform a lead assessment, 
properly notify tenants, and take other remedial measures.
    The conduct of Nuyen and Aneckstein was particularly serious 
because it involved deliberate attempts to disobey the law. Both 
engaged in numerous, well-planned, and repetitive violations. Both 
engaged in affirmative acts to obstruct regulators and grand juries in 
an effort to cover-up their underlying failure to provide the lead 
hazard warnings required by the Lead Hazard Reduction Act. Both 
substantially undermined the investigative and prosecutorial process. 
My message to the James T. Anecksteins and the David D. Nuyens of the 
world is that landlords and property managers have an obligation to 
inform tenants of lead-paint. Deliberately failing to notify tenants of 
lead hazards, especially in those instances where actual hazards are 
known, and lying to agencies entrusted with protecting public health 
and safety, are serious crimes. The Department of Justice is committed 
to working with our partners at HUD and EPA to fully investigate and 
prosecute such violations.

Conclusion
    Childhood lead poisoning is a completely preventable threat to 
children. I believe that most of the real estate and housing community 
are law-abiding citizens who want to do the right thing, and the civil 
and criminal enforcement actions taken to date have helped to educate 
them so that we can have better compliance with the law and lead-safe 
housing for our children. We are proud to be working with our partners 
at HUD, EPA, and State and local enforcement agencies on this effort, 
and look forward to bringing more successful actions to protect 
America's kids, especially those disadvantaged ones who are at greatest 
risk. With your continued support, we believe that we can move a long 
way toward eliminating lead poisoning.
    I look forward to working with the Subcommittee on this important 
issue and will be happy to answer any questions that you may have.

                               ----------
                    PREPARED STATEMENT OF ADAM SHARP
                   Associate Assistant Administrator
         Office of Prevention, Pesticides, and Toxic Substances
                  U.S. Environmental Protection Agency
                              June 5, 2002

Introduction
    Good afternoon, Mr. Chairman and Members of the Subcommittee. Thank 
you for the invitation to appear before you today. It is my privilege 
to represent the U.S. Environmental Protection Agency (EPA) and to 
discuss the Agency's efforts to prevent lead-based paint poisoning of 
our Nation's children.

Background
    In the almost 10 years since the Residential Lead-Based Paint 
Hazard Reduction Act of 1992 (Title X) was enacted, the U.S. 
Environmental Protection Agency, together with the U.S. Departments of 
Housing and Urban Development (HUD), Health and Human Services (HHS), 
and Justice, as well as our State partners, has made significant 
progress in eliminating childhood lead poisoning. In fact, interagency 
coordination within the Federal Government had started even earlier, 
dating to the 1980's, and now continues with a Presidential task force 
to ensure effective collaboration. How much progress have we made? In 
1978, there were nearly three to four million children with elevated 
blood-lead levels in the United States. In the 1990's, that number had 
dropped to 890,000 kids, and it continues to decline. While we still 
have a significant challenge, particularly with minority children and 
children living in low-income housing, EPA is very proud of how the 
Federal agencies and our State and private sector partners have 
coordinated their efforts with the public to better protect our 
children.
    The Federal Government has phased out lead in gasoline, reduced 
lead in drinking water, reduced lead in industrial air pollution, and 
banned or limited lead used in consumer products, including toys, mini-
blinds, food cans, glazed china and ceramic wear, crystal, and 
residential paint. States and municipalities have set up programs to 
identify and treat lead-poisoned children and to rehabilitate 
deteriorated housing. Parents, too, have greatly helped to reduce lead 
exposures to their children by cleaning and maintaining homes, having 
their children's blood-lead levels checked, and promoting proper 
nutrition.

Current Activities
    Many of the remaining cases of elevated blood-lead levels in 
children are caused by leaded paint and related sources in older 
housing. EPA has an active, multi-
pronged program to combat this problem. EPA's primary goal is to 
prevent children from being poisoned and avoiding the consequences 
associated with it. The program includes creating a national regulatory 
infrastructure, developing outreach and education programs aimed at 
those most at risk, and educating those who can help address the 
problem. The program also conducts technical studies to determine the 
overall risk of exposure and how our children can be better protected.

Regulations
 On March 6, 1996, EPA, together with HUD, promulgated the 
    Residential Lead-based Paint Real Estate Disclosure Rule (Toxic 
    Substance Control Act (TSCA) Sec. 1018). This rule mandates lead-
    based paint disclosure requirements for all sales and rentals of 
    pre-1978 housing, thus ensuring that homebuyers and renters are 
    made aware of lead-based paint hazards before deciding on a 
    dwelling, and, in the case of homebuyers, guarantees the right to a 
    lead inspection before purchase.
 On August 28, 1996, EPA promulgated a rule covering Training 
    and Certification for Lead-Based Paint Professionals in Target 
    Housing and Child-Occupied Facilities (TSCA Sec. 402(a)). This rule 
    ensures that a well-trained cadre of lead inspectors, risk 
    assessors, and abatement personnel is available. In addition, this 
    rule allows EPA to authorize individual States, Tribes, and 
    Territories to develop and administer training and certification 
    programs, thus extending the reach of these efforts. At present, 36 
    States, Puerto Rico, two Tribes, and the District of Columbia, 
    assisted by Federal grants, are authorized to carry out this 
    program, with EPA retaining direct authority in the remaining 
    areas.
 On June 1, 1998, EPA promulgated the Pre-Renovation Education 
    Rule (TSCA Sec. 406(b)). This rule implements a very simple 
    concept: All owners/tenants of pre-1978 housing (about 15 million 
    housing units) should be given basic information about lead 
    poisoning prevention before paint-disturbing renovations are 
    started. EPA is continuing to work closely with advocacy groups and 
    the regulated community to ensure that this rule is effective and 
    not overly burdensome.
 On January 5, 2001, EPA promulgated a rule on the 
    Identification of Hazardous Levels of Lead in Dust and Soil (TSCA 
    Sec. 403). This rule defines certain locations and conditions of 
    lead-based paint, and specific levels of lead in dust and soil that 
    are most likely to pose a health threat to children. These 
    standards effect disclosure provisions, the need to use trained, 
    certified lead workers, and control and abatement requirements for 
    Federally-owned and Federally-assisted housing.

Outreach and Education
    EPA conducts extensive outreach with potentially affected parties 
in the development of regulations, to assist regulated parties in 
complying with regulations, to inform citizens of their rights under 
these rules and to inform the public about the nature of lead-based 
paint hazards and provide guidance on how to reduce risks. Our partners 
at HUD and HHS' Centers for Disease Control and Prevention (CDC) 
partially fund these activities and provide technical support. This 
outreach includes:

 A bilingual National Lead Information Center (1-800-424-LEAD). 
    The Center 
    operates a national hotline handling over 60,000 contacts per year, 
    distributes 
    1.6 million documents annually and operates a national 
    clearinghouse where best practices are shared.
 Development of materials, such as brochures and sample real 
    estate disclosure forms, needed to comply with regulatory 
    requirements.
 Creation and distribution of educational materials and 
    national lead awareness campaigns for parents, homeowners and 
    renters, medical professionals, renovation contractors and ``do-it-
    yourselfers,'' and others. This includes the award-winning, 
    bilingual ``Get the Lead Out'' campaign to increase the awareness 
    of lead-paint 
    hazards.
 Partnership programs with nonprofit groups and other 
    Government agencies to conduct lead awareness/education activities, 
    particularly targeted to minority and urban populations often most 
    at risk.
 Cooperative programs with retail stores to distribute EPA 
    materials where painting or renovation supplies are sold.
Technical Studies
    EPA has conducted numerous studies to define the levels of exposure 
that should be regarded as hazardous to children and identify work 
practices that successfully reduce lead-based paint risks. EPA's goal 
is to better understand lead exposures, ensure that testing is done 
appropriately and reduce the cost associated with eliminating exposure. 
EPA's technical program includes:

 Technical studies, including risk assessments to support 
    regulatory decisions.
 Reports on lead testing and methodologies.
 Management of a national lead laboratory accreditation 
    program.

    Even though we have accomplished a great deal, there is still more 
to be done. The EPA is looking for better technologies to make lead 
hazard control work more 
affordable. For example, the Agency is working with HUD on spot test 
kits for lead detection. As EPA Administrator Christine Todd Whitman 
has stated, the Agency must base its decisions on sound science. To 
that end, EPA is now engaged with HUD in peer review of the new spot 
test kit work. We are also working with the National Association of 
Realtors, the National Multihousing Council, and others to reassess and 
streamline our prerenovation education requirements.

New Regulatory Activities
    EPA anticipates completing the regulatory program mandated by Title 
X over the next few years. Our renovation and remodeling activities, 
which include new rulemaking, will address how to safely remove lead-
based paint and debris during remodeling activities. The Agency has 
completed the Small Business Advocacy Review panel process and plans 
additional consultation with States and the business community this 
Autumn. We anticipate that a proposed rule will be ready for 
publication in 2003.
    In the meantime, EPA has developed a model training course for 
renovation contractors, which is intended to provide them with 
recommended methods to minimize lead hazards. The Agency is also 
developing an outreach campaign to expand acceptance and use of the 
model course. The goal is to promote lead-safe work practices among all 
home remodelers, both professionals and ``do-it-yourselfers,'' and to 
ensure proper training.
    EPA anticipates publishing a proposed rule addressing lead-based 
paint activities on bridges and structures in 2004. We are looking 
closely at guidance for containing paint debris developed by the 
Society for Protective Coatings (formerly the Steel Structures Painting 
Council--SSPC), an association for users and suppliers of industrial 
protective coatings and related products and services. SSPC's guidance 
is increasingly being relied on by public and private entities engaged 
in deleading activities, and is referenced in State regulations 
governing these activities.
    In addition, because of the impact the regulation could have on 
small communities, EPA is conducting outreach in several States through 
the Small Communities Outreach Project for Environmental Issues, under 
a cooperative agreement with the National Association of Schools of 
Public Affairs and Administration. This initiative is a community-based 
approach to engaging elected officials and local government staff at 
the early stage of regulatory development.
    EPA expects to finalize regulations on management and disposal of 
lead-based paint debris by the end of 2002. The Agency proposed the 
rule in 1998 to address concerns expressed by HUD, HHS, some States, 
advocacy groups and the regulated community that the costs of testing, 
management, and disposal of lead-paint debris can be a significant 
obstacle to abatement financing. EPA's Office of Solid Waste 
is completing a rule that allows this debris, including chips, dust, 
and sludge, to be disposed of in construction and demolition landfills. 
This will result in significantly lower waste management and disposal 
costs. EPA is also now working to introduce common-sense controls for 
on-site storage of lead-based paint debris prior to disposal.

Conclusion
    Thank you for the opportunity to discuss some of EPA's 
contributions to prevent lead-based paint poisoning, just a part of our 
successful Federal collaboration on this issue. Again, I want to thank 
you for your support and assure you that this Administration is looking 
forward to working with the Subcommittee to achieve our goal to 
eliminate childhood lead poisoning by 2010. I would be pleased to 
answer your questions.

                               ----------
                 PREPARED STATEMENT OF RUBEN-SHAW, JR.
            Deputy Administrator and Chief Operating Officer
                Centers for Medicare & Medicaid Services
                              June 5, 2002

    Chairman Reed, Senator Allard, distinguished Subcommittee Members, 
thank you for inviting me to this hearing today to discuss the Centers 
for Medicare & Medicaid Services' (CMS) efforts to address lead-based 
poisoning in children. Specifically, I would like to discuss CMS' role 
in providing screening and treatment for at-risk children. Despite 
dramatic reductions in blood-lead levels over the past 20 years, lead 
poisoning continues to be a significant health risk for young children, 
particularly those from low-income families or who live in older 
housing. I know that you, Chairman Reed, have a keen interest in this 
issue, and we recognize and appreciate your efforts and the work of 
this Subcommittee.
    Although lead poisoning is a preventable condition, it remains a 
health concern for America's children. Administrator Scully and I share 
your concern regarding the very real dangers posed by lead poisoning, 
and I want to emphasize CMS' commitment to protecting the health and 
well-being of America's children. We are committed to following 
Secretary Thompson's lead on prevention efforts and to working with our 
sister agencies at the Department of Health and Human Services, 
especially CDC, to eradicate this health concern. To this end, we are 
engaged in a number of efforts to address lead poisoning in children, 
which I will detail for you today.

CMS' Role in Preventing Lead Poisoning
    The fight to eradicate poisoning from lead-based paint and dust is 
a collaborative effort, and CMS works closely with other HHS agencies, 
such as the Centers for Disease Control and Prevention (CDC), as well 
as the Environmental Protection Agency (EPA), the Department of Housing 
and Urban Development (HUD), the Department of Justice (DOJ), and other 
community-based organizations. Medicaid plays a distinct role in 
addressing lead poisoning by providing funding for four important 
services: Screening, treatment, investigation, and case management for 
eligible Medicaid beneficiaries.
    Medicaid's Early and Periodic Screening, Diagnostic, and Treatment 
(EPSDT) benefit specifically requires that all Medicaid-eligible 
children receive a screening blood-lead test at 1 and 2 years of age, 
as recommended by the CDC. Also, any child over age 2 up to age 6 for 
whom no record of a test exists must receive a screening blood-lead 
test. In addition to paying for the screening tests, Medicaid pays for 
any additional diagnostic and/or treatment services required for a 
child with elevated blood-lead levels. This includes any case 
management services necessary to ensure that the child and family are 
directed to the appropriate agencies and resources they may need, such 
as the local health department and housing agencies, medical care, and 
facilities. Once a child is diagnosed as having an elevated blood-lead 
level, Medicaid also will pay for a one-time investigation. During this 
investigation, a health professional visits a child's home (or primary 
residence) and inspects the area to determine the source of lead. We 
believe that Medicaid has contributed to the dramatic decline in blood-
lead levels over the last two decades, however, we are 
continuing to make improvements in data collection and education with 
our State 
partners, as well as health care providers.

CMS' Collaborative Efforts and Improvement Strategy
    As you may know, the General Accounting Office (GAO) released a 
report in January 1999 that detailed problems in the Federal response 
to children at risk for elevated blood levels. This report provided a 
roadmap for improvement, and following its publication, CMS entered 
into a number of activities to improve our services and commitment to 
helping at-risk children. For example, in 1999, we began efforts to 
improve the way we collect data on screening tests by adding a line 
item to the annual EPSDT report that States submit to us. This line 
item indicates the number of children under the age of 6 that received 
a screening blood-lead test. We began collecting this data in April 
2000 for fiscal year 1999. However, the reporting of tests and test 
results always presents a challenge for the Agency. We only gather 
information on the tests we help to fund. Some tests provided by local 
health departments through health fairs and other venues are not 
generally billed to Medicaid. When no Medicaid claim for the test 
exists, accounting for these tests for the purpose of our annual EPSDT 
report is made more difficult. We have continued to encourage State 
Medicaid agencies to participate in data sharing activities so that the 
local health department and the Medicaid Agency are both aware if a 
test has been performed on a Medicaid-eligible child. Moreover, our 
Regional Offices work with State and local agencies to help coordinate 
and support grassroots efforts to educate providers on the importance 
of blood-lead screening, reporting, and data 
collection.
    Also in 1999 in response to the GAO report, we sent a letter to all 
State Medicaid directors that detailed the findings of the report and 
reiterated the responsibilities of each State Medicaid program under 
the Federal Medicaid screening policy. This letter also encouraged 
States to develop model interagency agreements to share best practices 
information among the agencies in their State governments. That way, 
States can better assess the areas and children that lead may affect, 
and how to prevent and detect lead poisoning.
    Building on these efforts, we also have entered into a Cooperative 
Agreement with the Alliance to End Childhood Lead Poisoning, awarding 
them $250,000 to develop an educational tool to be used by regional, 
State, and local Medicaid offices, and other entities who work closely 
with health care providers and managed care plans involved in screening 
children. The tool is intended to improve awareness of and compliance 
with the CMS policies on childhood lead poisoning prevention. Our 
collaborative effort resulted in the development of a guide entitled, 
Track, Monitor and Respond: Three Keys to Better Lead Screening for 
Children in Medicaid, which was disseminated to State Medicaid Agencies 
and is available on the Alliance website. This guide is intended to be 
an educational document that States can use to reach out to their 
providers in order to resolve some of the difficulties in the provision 
of the blood-lead screening tests.
    In addition to our work with the Alliance, we have awarded a 
contract for approximately $750,000 to Abt Associates to develop a 
study titled, Moving Toward Elimination of Lead in High-Risk Children. 
The purpose of this study is twofold: To improve screening among low-
income children by assessing the impact and effectiveness of current 
screening criteria in reaching high-risk, low-income children (with a 
particular emphasis on Medicaid-eligible children); and to identify 
State and local innovations for the elimination of lead hazards facing 
low-income children. The study is ongoing and will identify and analyze 
current screening policies and practices for low-income children to 
determine the extent to which Medicaid and other high-risk children are 
being screened and whether programs are achieving successful results. 
The project will include site visits to five locations to provide an 
in-depth picture of the screening and prevention/remediation activities 
in five areas--Providence, Rhode Island; Baltimore, Maryland; Chicago, 
Illinois; the State of Iowa; and Oakland/Alameda County, California. We 
expect a final report by Fall 2002. We plan to share this report with 
State Medicaid agencies to assist them in developing the types of 
processes and practices that will result in more high-risk Medicaid-
eligible children receiving the lead screening test to which they are 
entitled. We believe that the study will show that if local housing and 
health departments and State Medicaid agencies work together, a child's 
chances of being screened for lead poisoning and being able to live in 
lead-safe housing greatly improve.
    Just as local and State agencies need to cooperate, Federal 
agencies must work together, too. We collaborate with many other 
Federal agencies on the President's Task Force on Environmental Health 
Risks and Safety Risks to Children. In February 2000, the Task Force 
published ``Eliminating Childhood Lead Poisoning: A Federal Strategy 
Targeting Lead Paint Hazards.'' The report presents a program for 
eliminating childhood lead poisoning by 2010 based on coordinating the 
efforts of various Federal agencies, including HUD, EPA, CDC, and CMS 
to improve early intervention and follow-up services for at-risk 
children and to remove lead hazards from homes. We look forward to 
working with our partner agencies and departments and the States to 
address the full array of issues surrounding the elimination of 
childhood lead poisoning.
    As we strive to develop a number of strategies to better protect 
America's at-risk children, we remain committed to our current policy 
addressing the very real threat posed by lead hazards. Moreover, while 
we work to ensure that at-risk children, particularly those who are 
Medicaid-eligible, receive early intervention and treatment for lead 
poisoning, we will continue to rely on the expertise of the CDC for 
policy recommendations on lead screening.

Conclusion
    National health surveys conducted periodically by the CDC have 
shown a marked decline in the prevalence of elevated blood-lead levels 
in children, primarily due to regulatory bans on lead in gasoline and 
paint. However, lead poisoning still presents a serious developmental 
health risk for many American children, including those from low-income 
families or who reside in older housing that may contain lead-based 
paint. Under the Secretary's leadership, Administrator Scully and I 
remain committed to helping eradicate this preventable health 
condition. Although our particular role in the fight to eliminate lead 
poisoning in children lies in reimbursing for secondary preventive 
services such as lead screening and any additional diagnostic and 
treatment services required by those Medicaid-eligible children with 
lead poisoning, we here at CMS are dedicated to working with State 
Medicaid Agencies, local organizations and our sister agencies and 
other Federal departments to develop innovative strategies to combat 
lead poisoning in the 21st Century. I want to thank the Subcommittee 
for your interest in this important health problem that 
affects primarily underserved children, and I would again like to thank 
Chair-
man Reed for his leadership regarding this issue. I look forward to 
answering your 
questions.

                               ----------
         PREPARED STATEMENT OF RICHARD J. JACKSON, M.D., M.P.H.
           Director, National Center for Environmental Health
               Centers for Disease Control and Prevention
              U.S. Department of Health and Human Services
                              June 5, 2002

    Good afternoon. I am Dr. Richard Jackson, Director of the National 
Center for Environmental Health (NCEH), of the Centers for Disease 
Control and Prevention (CDC), U.S. Department of Health and Human 
Services. I would like to thank Senator Reed and the Senate Banking 
Subcommittee on Housing and Transportation for inviting me here today. 
It has been an honor for me to take part in the collabo-
ration between CDC, CMS, HUD, EPA, and DOJ that has formed around this 
effort. I am pleased to be here to discuss CDC's Childhood Lead 
Poisoning Prevention Program.
    In 1991, the U.S. Department of Health and Human Services (DHHS) 
called for a society-wide effort to eliminate childhood lead poisoning 
in 20 years, and 11 years later, we remain committed to this goal. The 
elimination of this preventable disease will be one of the major public 
health accomplishments of this century.
    It is clear that lead can do great harm, especially to young 
children. A child's exposure to lead can produce serious health 
consequences, including a variety of neurologic and behavioral 
disturbances, as well as delayed development. Over the past 25 years, 
we have been successful in reducing our children's blood-lead levels 
nationwide. The CDC's analysis of children's blood-lead levels as part 
of the National Health and Nutrition Examination Survey (NHANES II) 
conducted between 1976 and 1980 revealed that 88 percent of American 
children between the ages of 1 and 5 had elevated blood-lead levels 
(EBLL) (*10 g/dL). Further, CDC analyses were instrumental in revealing 
that decreasing lead in gasoline resulted in parallel declines in 
blood-lead levels. This information contributed to the subsequent U.S. 
Environmental Protection Agency (EPA) decision to remove lead from 
gasoline. This decision, along with the removal of lead from paint and 
other sources, has resulted in a dramatic decline in the amount of lead 
in the blood of all Americans. According to CDC's NHANES data from 
1991-1994, the proportion of children age 1-5 years with elevated 
blood-lead levels had fallen from 88 percent to 4.4 percent.
    Through this work, CDC has recognized that having good measures of 
the actual exposure of the American public to lead was going to be 
critical to achieving our goals. NHANES has allowed us to focus on 
identifying children who are at higher risk for lead poisoning. 
Children who have been found to be at higher risk include children from 
low-income families who live in older deteriorated housing; many are 
minority children. CDC data also indicate that there are currently an 
estimated 890,000 American children under the age of 6 who have 
elevated blood-lead levels.
    I will now turn to describing the activities of CDC's Childhood 
Lead Poisoning Prevention Program. This program was authorized under 
Section 317A of the Public Health Service Act as amended in 1988. The 
program was reauthorized in 1992 as part of the Preventive Health 
Amendments Act, and in 1998, reauthorization was extended to 2002. The 
program received its first appropriation in 1990, and is currently 
funded at $41 million for fiscal year 2002. With these funds, CDC 
provides guidance, technical support, and resources to 43 States and 17 
local health departments for childhood lead poisoning prevention and 
surveillance efforts. These CDC supported programs include three main 
components which I will describe in detail, in addition to other 
elements. The main components are: (1) Primary Prevention; (2) 
Effective Screening and Surveillance; and (3) Public and Professional 
Health Education and Communication.

Primary Prevention
    CDC supports innovative approaches to identifying children at risk 
for lead exposure and ensuring their housing is lead-safe before they 
are exposed to lead. In addition, CDC supports the development, 
improvement, and oversight of policies and strategies to bring about 
primary prevention within all funded programs. For example, Maryland 
law mandates a paint maintenance standard-of-care for all rental units 
built before 1950, with third-party inspection prior to each rental 
turnover. Over half of the Maryland's 159,000 pre-1950 rental units 
have registered with the Maryland Lead Rental Registry. Over 75,000 
third-party inspections to certify that pre-1950 rental units meet the 
lead standard-of-care have been conducted and reported to the State. 
Tenants can now call to check if a property has been registered and 
inspected before they rent. Through its cooperative agreement with 
Maryland, CDC provides expertise and funding to assist the State with 
this innovative approach.

Effective Screening
    CDC provides national guidance for the prevention of childhood lead 
poisoning, including Screening Young Children for Lead Poisoning: 
Guidance for State and Local Public Health Officials. This document 
provides general guidelines about the roles and responsibilities of 
child health-care providers in preventing childhood lead poisoning, 
screening and follow-up testing, clinical management, chelation 
therapy, and family education about EBLL's. For example, as recommended 
by CDC guidance, North Carolina has a statewide screening plan that 
targets 1- and 2-year-olds and other high-risk populations, especially 
Medicaid and Women, Infants, and Children (WIC) program recipients. 
Since the targeted screening plan was adopted in October 1998, the 
annual screening rate among all 1- and 2-year-olds in the State has 
increased from 25 percent (53,390 tested in 1998) to 35 percent (81,988 
tested in 2001). Essential to this effort have been promotional efforts 
by the State Medicaid Agency and a statewide WIC screening initiative 
targeting children who have never been tested.
    However, a U.S. General Accounting Office (GAO) report from 
February 1998 entitled, ``Medicaid: Elevated Blood Lead Levels in 
Children,'' suggests that many States are not screening children at 
risk for lead exposure. CDC recognizes this challenge, and the new 
screening guidance addresses the issue of reaching children enrolled in 
Medicaid and other health care programs.
    One way CDC is addressing this issue is by providing technical 
assistance to funded States for developing and enhancing the States' 
Childhood Blood Lead Surveillance (CBLS) system. The inclusion of State 
data in CDC's CBLS database provides a national picture of childhood 
blood-lead levels. Establishing childhood lead surveillance systems at 
the State levels allows the use of surveillance data to estimate the 
extent of EBLL's among children, assess the follow-up of these 
children, and help allocate resources for lead poisoning prevention 
activities within each specific State. Minnesota's Department of Health 
(MDH), for example, maintains an extensive blood-lead surveillance 
system for monitoring trends in blood-lead testing and BLL's in 
children. MDH matches lead surveillance data with Medicaid data to 
analyze screening trends and determine the percentage of Medicaid 
children screened with EBLL's. Through this analysis, MDH has been able 
to determine that in Minnesota 72 percent of children with EBLL's were 
enrolled in Medicaid. In addition, Medicaid-enrolled kids had nearly 
twice the rate of EBLL's than kids not enrolled in Medicaid (9.8 
percent vs. 5.0 percent).
    CDC provides screening and case management guidelines to all CDC 
funded programs. Working in conjunction with CDC, all funded programs 
develop, implement, and evaluate their activities to assure that 
children receive the best care possible. For example, Rhode Island uses 
the KIDSNET system, an automated tracking and follow-up tool, that 
links pediatric public health programs to each other and to health care 
providers. KIDSNET provides contextual information about the number of 
children who should be screened to determine screening rates and 
provides data which enables the State to evaluate the quality of 
screening and follow-up at the provider level.

Public and Professional Health Education and Health Communication
    CDC conveys the negative health effects of elevated blood-lead 
levels to a child and the importance of screening through public 
outreach and professional education. CDC supports and provides 
oversight to funded programs to target audiences such as parents, 
doctors, nurses, public health professionals, and rental property 
owners. Information is dispersed through TV and radio announcements, 
educational pamphlets, training courses, and policy briefings. Salt 
Lake Valley (UT) Health Department's Lead Free Kids program has 
identified realtors and landlords as a target audience. The goals of 
the project include providing unaware landlords and realtors with 
information on disclosure regulation requirements and raising tenant 
awareness of lead-based paint hazards. Some of the outreach components 
include direct mailing of a lead disclosure brochure to area realtors, 
pre-1978 multifamily property owners and members of the Utah Apartment 
Association (UAA), and submitting articles in the realtor and apartment 
owners' trade journals.
    CDC's activities in these areas have evolved over time, and one of 
the lessons that we have learned is that in order to meet our goal, we 
must pay attention to changes in our environment and adopt new 
approaches. In 2001, CDC developed the High-Intensity Targeted 
Screening (HITS) approach for improving the Nation's ability to target 
and screen children for lead poisoning and prevent exposure to lead. 
The goals of HITS are to identify children missed by routine screening; 
improve surveillance and estimate the burden of lead poisoning in a 
specific locale; evaluate current screening plans; develop 
partnerships; and increase local capacity. HITS teams, which are made 
up of the staffers from local childhood lead poisoning prevention 
programs and community members, assisted by CDC, visit homes in high-
risk communities to screen children for lead. When children are found 
to have EBLL's, the families are offered appropriate medical treatment 
and a home lead evaluation. Local programs will use HITS data to 
improve lead screening plans, better direct resources, increase 
technical capacity, and monitor progress toward lead poisoning 
elimination. The HITS approach requires partnerships to be developed 
between community members and multiple Federal, State, and local 
agencies resulting in a more comprehensive approach to eliminating 
childhood lead poisoning at the local level.
    In November 2001, the first HITS project in two inner-city 
communities in Chicago was completed. Preliminary analyses indicate 
that 67 percent of the children had never been previously tested, and 
approximately 30 percent of the children who were tested had EBLL's. 
Data analysis is ongoing. CDC plans to implement HITS in additional 
communities over the next several years in order to improve the 
Nation's ability to target and screen children for lead poisoning and 
prevent exposure to lead.
    Just as we have emphasized the importance of collaborative 
activities at the State and local level to develop a successful 
statewide screening plan, we have redoubled our efforts to collaborate 
with other Federal agencies to make the goal of eliminating childhood 
lead poisoning a reality. Since 1990, there has been a Federal 
partnership to focus our efforts toward this goal, with the DHHS 
(particularly CMS), 
EPA, and U.S. Department of Housing and Urban Development (HUD) taking 
leadership roles.
    CDC and its grantees work very closely with HUD and HUD's grantees 
to ensure the prevention of childhood lead poisoning. The close 
coordination maximizes the 
resources of each organization without duplicating services. Each grant 
program draws upon its unique expertise and service delivery networks. 
CDC grantees have expertise in technical issues related to screening 
and blood-lead testing, as well as programmatic expertise in following 
up on the needs of high-risk children. HUD grantees have expertise in 
lead-based paint and lead dust hazard identification and in the 
physical interventions needed to make homes lead-safe.
    HUD grantees concentrate their primary prevention activities in 
neighborhoods where children are at risk for lead poisoning. Data from 
CDC and its grantees are essential for HUD grantees to appropriately 
target their primary prevention efforts. Furthermore, HUD grantees work 
closely with CDC grantees to reduce lead hazards in housing where 
children are identified as lead-poisoned. This serves the goal of 
secondary prevention, as well as the goal of preventing additional 
children from being lead-poisoned. CDC also funds 35 States to track 
the problem of adult lead exposure through the Adult Blood Lead 
Epidemiology and Surveillance (ABLES) program. This program helps 
prevent lead exposures in children whose parents are exposed to lead at 
work and who may inadvertently bring contaminated clothing into the 
home. Together, CDC and HUD can identify and intervene with both at-
risk children and at-risk home environments, moving us closer to 
eliminating childhood lead poisoning by 2010.
    In closing, I would like to emphasize that we will continue to face 
challenges in the elimination of childhood lead poisoning prevention, 
but CDC and our partners in this effort have learned many lessons over 
the past decade that have prepared us well. In any public effort such 
as this, one of the biggest challenges we face is to keep resources and 
attention focused on a problem over time. It is important to remember 
that no child in this country should be adversely impacted by 
environmental exposure to lead. The improvement in quality of life for 
the children freed from the threat of possible damage caused by 
exposure to lead cannot be overstated. Our children, the most important 
resource for the future, deserve our every effort. We have come a long 
way in making children lead-free, and I appreciate your interest and 
support in continuing to make this vision a reality.
    That concludes my written statement. At this time, I would be happy 
to answer your questions.

         RESPONSE TO WRITTEN QUESTIONS OF SENATOR REED 
                      FROM DAVID E. JACOBS

Q.1a. What is HUD doing to make sure its new lead-safety 
regulations are being followed or enforced?

A.1a. HUD has prepared several tools and training activities to 

ensure that the new HUD lead-safety regulation is being 
followed in each program area. HUD implemented a transition 
assistance period that lasted from September 15, 2000 until 
January 10, 2002 to enable local jurisdictions to build the 
necessary capacity to comply with the rule. Now that the 
transition period has ended, HUD is ensuring that its routine 
program monitoring includes an evaluation of compliance with 
the new regulation in its housing maintenance, rehabilitation, and 
other subsidy programs covered by the regulation. In addition, 
HUD staff in the Office of Healthy Homes and Lead Hazard 
Control will be combining compliance checks for both the lead-
paint disclosure regulation and the new HUD lead-safety 
regulation in selected geographic areas where lead hazards are 
most prevalent. Increased staff are now on board to handle this 
increased workload.

Q.1b. Why is HUD's Single-Family Mortgage Insurance Program the 
only program not to be updated in HUD's new lead-paint 
regulations for assisted housing? Is there a significant 
incidence of lead exposure and contamination in these units?

A.1b. HUD's Single-Family Mortgage Insurance Program currently 
requires that properties have a visual inspection, paint repair 
if lead is present, post repair clean-up, and disclosure to the 
buyer. An analysis completed in the late 1990's estimated that 
the imposition of the new assisted housing lead-paint 
regulations would cost an estimated $93 million annually, costs 
that could be passed on to the homebuyer and have the effect of 
diminishing new homeownership opportunities. HUD does not have 
data on the specific incidence of lead-paint hazards in homes 
served by the Single-Family Mortgage Insurance Program.

Q.2a. How much funding would Congress have to provide you with 
in order to fund all of the applications you have received?

A.2a. For fiscal year 2001, the Office of Healthy Homes and 
Lead Hazard Control received 181 applications totaling $290 
million. Each applicant was limited to requesting no more than 
$3 million each. Congress appropriated $100 million for fiscal 
year 2001, $110 million for fiscal year 2002, and the 
President's budget request for fiscal year 2003 is $126 
million.

Q.2b. Have requests for such assistance increased as a result 
of the promulgation of new HUD lead-based paint regulations 
(September 15, 2000)?

A.2b. There does not appear to be a large increase in requests 
for assistance as a result of the new HUD lead-based paint 
regulations.

Q.3a. What tools are needed to encourage the practice (of 
leverag-
ing lead hazard control and rehabilitation funding with the 
Department of Energy's weatherization funding)?

A.3a. A better system of identifying those lead hazard control 
practices that promote energy efficiency and vice versa is 
needed to 
enable an improved estimate of the benefits of such leveraging. 

Window replacement is perhaps the most common work activity 
that accomplishes both improved energy efficiency and lead 
hazard control simultaneously, but there are undoubtedly other 
opportunities as well.

Q.3b. What tools are needed to make weatherization work 
practices consistent with lead-safe work practices to ensure 
that our children are protected in homes undergoing 
weatherization?

A.3b. A uniform training curriculum is needed to ensure 
weatherization workers receive consistent messages in DOE-
sponsored training courses. This could be achieved by adapting 
EPA's lead-safe remodeling and renovation work practices course 
to weatherization, in much the same way that HUD adapted this 
course for use in assisted housing. Clearance testing should 
also be made an eligible weatherization expense for those jobs 
that disturb lead-based paint above de minimis levels.

Q.4. How many (Project-Based Section 8) owners have actually 
used this program (of free lead-paint inspections/risk 
assessments)? What percentage of the total inventory do these 
owners make up?

A.4. There are approximately 11,000 properties built before 
1978 in the Project-Based Section 8 inventory. To date, 3,131 
properties have enrolled in the HUD program providing free 
lead-based paint risk assessments and lead inspections. This 
constitutes approximately 29 percent of the inventory. In 
addition, HUD is aware that some owners have contracted for 
their own lead-based paint inspections, either voluntarily or 
as a result of local lead-based paint enforcement activities. 
Recently, HUD sent to each owner a letter and certification 
form to document each property's lead-safety status. The 
compliance deadline for completing risk assessments for the 
project-based units built between 1960 and 1977 (which 
constitutes about 9,000 of the 11,000 properties covered by the 
regulation) is September 15, 2003.

Q.5. How many HUD cases have been referred to DOJ in the last 
year and a half ? What is the status of those cases?

A.5. In the past year and a half, HUD has pursued 15 cases with 
the Department of Justice, four of which have been formally 
referred to DOJ. Ten other cases have been completed with DOJ 
since 1998. HUD is also currently investigating dozens of other 
cases administratively. These cases are in various stages of 
investigation and negotiation. HUD and DOJ expect to continue 
to announce resolution of cases of noncompliance as consent 
decrees or other legal actions are completed.

Q.6. Do you believe that visual inspection, lead-safe work 
practices and clearance testing offer the potential to expand 
lead-safety on a broad enough scale to make U.S. housing lead-
safe?

A.6. Yes, this strategy is likely to be effective for most 
housing with low risk and adequate cash flow to support good 
maintenance practices. HUD has developed a short web-based 
training course for visual assessment to help meet this need. 
Together with EPA, we have also developed several maintenance 
courses to teach lead-safe work practices. But for unassisted 
low-income housing where cash flow and maintenance is 
inadequate and where deteriorated paint is extensive, other 
strategies are needed. Risk assessments and/or inspections will 
enable a more targeted approach so that lead-based paint 
hazards are correctly identified and controlled at minimum 
cost. Most deteriorated paint, even in older housing, is not, 
in fact, lead-based paint and therefore does not need to be 
addressed in order to make a property lead-safe. A visual 
assessment alone cannot determine the presence of lead in 
paint, or dust-, or soil-lead hazards.
    For example, the high-risk housing treated under HUD's Lead 
Hazard Control Grant Program is always given a risk assessment 
and/or inspection to ensure that a targeted approach is used. 
Properties that have consistently high rates of deferred 
maintenance will need to be abated; other properties can be 
assessed visually, with follow-up lead-safe work practices and 
with clearance testing completed. The degree of hazard control 
should reflect the degree and extent of hazard. In the worst 
cases, demolition may be the best option.

Q.7. What do you believe your Agency can do to help stop houses 
from poisoning more than one child?

A.7. HUD's new lead-safe housing regulation requires that 
houses with lead-poisoned children and lead-based paint hazards 
must be made lead-safe before the unit can qualify for 
continued subsidy, even if the lead-poisoned child has been 
relocated to another unit. In addition, HUD program recipients 
and local health departments are required to compare lists of 
subsidized housing units with lists of lead-poisoned children 
on a quarterly basis. If there is a match, then HUD's lead 
hazard control requirements apply to that unit as a condition 
of continued subsidy. Also, some of HUD's lead hazard control 
grantees, such as Milwaukee, use HUD funds to leverage 
substantial private-sector investment in properties where 
children have been poisoned if the owner agrees to act quickly 
to eliminate the hazards.
    The State of Rhode Island, which has received substantial 
funding from HUD for lead hazard control, recently passed a new 
State law that increases an owner's responsibility in houses 
that have poisoned more than one child. Finally, in last year's 
appropriation, Congress created an earmark to the National 
Center for Lead-Safe Housing to develop a database of lead-
based paint activities. Through that organization, HUD is 
working with several cities to pilot-test a database that could 
include information on houses that have poisoned more than one 
child, after resolution of issues regarding confidentiality of 
medical records.

Q.8. What does your Agency believe might be appropriate 
statutory changes to make the Federal disclosure law regarding 
lead more meaningful?

A.8. HUD does not currently have subpoena authority under Title 
X of the 1992 Housing and Community Development Act to enforce 
the Federal disclosure regulation. Because the disclosure 
regulation is a joint HUD/EPA regulation, HUD has relied on 
EPA's subpoena authority under the Toxic Substances Control 
Act. While the collaboration between the two agencies has worked 
well, the lack of HUD subpoena authority creates unnecessary 
administrative obstacles. HUD currently has subpoena authority 
to investigate other statutory requirements, such as the Real 
Estate Settlement Procedures Act (RESPA).
    Also, HUD does not have statutory authority to delegate to 
local jurisdictions the environmental review function for the 
Healthy Homes and Lead Hazard Control programs. Environmental 
reviews are required under the National Environmental Policy 
Act. Local jurisdictions are best able to make the most 
informed assessments. Other HUD programs, such as the Community 
Development Block Grant (CDBG) and Housing Opportunities for 
People With AIDS (HOPWA), currently have statutory authority to 
delegate the environmental review function to local 
jurisdictions.

Q.9. What does your Agency think about this strategy (of moving 
beyond screening children's blood-lead levels to actually 
screening high-risk housing to identify hazards before a 
child's health is harmed)? What about the idea of developing 
registries of hazardous properties?

A.9. HUD supports the strategy of screening high-risk housing, 
which is at the heart of HUD's lead-safe housing regulation. 
Several HUD lead hazard control grantees maintain lead-safe 
housing registries as a way of informing the public on where 
lead-safe housing is located (see answer to question 7 above). 
HUD does not currently have the statutory authority to create a 
national registry of hazardous properties.

Q.10. Does your Agency believe that lead-based paint and dust 
hazards in housing are the overwhelming cause of childhood lead 
poisoning in the United States? If not, what other causes 
should the Congress be looking at?

A.10. Lead-based paint hazards and the contaminated dust and 
soil it generates are clearly the major cause of childhood lead 
poisoning in the United States today. The President's Task 
Force Report references the available scientific evidence on 
this question.

Q.11. Does your Agency support the goal of stopping children 
from being poisoned in the first place? If so, how is your 
Agency planning to achieve this goal?

A.11. Yes, HUD supports the goal of stopping children from 
being poisoned in the first place. We are planning to achieve 
that goal by creating lead-safe housing that children are 
either born into or in which they are expected to reside in the 
future. HUD's Lead Hazard Control Grant Program, leveraged private 
sector funding and resources through Operation LEAP (Lead Elimination 
Action Program), HUD's lead-safe housing regulation for Federally-
assisted housing, enforcement of both that regulation and the 
lead disclosure regulation, public education, research, 
training, and coordination with other Federal, State, and local 
governments are the principal vehicles through which we expect 
to achieve the goal.

        RESPONSE TO WRITTEN QUESTIONS OF SENATOR CARPER 
                      FROM DAVID E. JACOBS

Q.1. Both HUD and EPA have repeatedly endorsed a ``lead-safe'' 
standard for lead hazard remediation, rather than ``lead-
free.'' These findings seem definitive and are based on good 
science, yet the issue continues to get attention. What is 
HUD's position on ``lead-safe'' versus ``lead-free?''

A.1. The two standards are not mutually exclusive; there are 
circumstances where one or the other is most sensible. Each 
standard is capable of eliminating excessive lead exposure and 
protecting children. A ``lead-safe'' standard means that while 
a property may have lead-based paint, it has no lead-based 
paint hazards; in other words, the mere presence of lead-based 
paint does not in itself constitute an immediate hazard. In 
order for the ``lead-safe'' standard to be effective, the lead-
based paint must be monitored and managed over time to ensure 
that it remains in a nonhazardous condition. Also, any 
activities that disturb the lead-based paint, such as 
renovation, remodeling, repainting, or maintenance, must be 
performed using lead-safe work practices and clearance testing 
to ensure cleanup has been adequately performed. Several 
studies, including HUD's study of its Lead Hazard Control Grant 
Program, have shown that this approach is effective in reducing 
both dust-lead levels and blood-lead levels in resident 
children.
    A ``lead-free'' standard may also be appropriate in cases 
where the lead-based paint will not be properly managed, where 
``gut'' rehabilitation will eliminate all surfaces coated with 
old paint, or where only a few surfaces in a given housing unit 
are coated with lead-paint. In these circumstances, it may make 
more sense to simply remove lead-based paint, rather than pay 
for the on-going management and maintenance of surfaces coated 
with lead-paint. Since the lead-based paint is removed, no on-
going maintenance or management is needed, because there is no 
potential for exposure to hazards. Furthermore, there is no 
additional disclosure or regula-
tory burden for properties that are free of lead-based paint.
    Under both standards, removal of either deteriorated or 
intact lead-based paint above de minimis levels should be 
performed using lead-safe work practices, followed by 
specialized cleaning and clearance testing. HUD and several 
local jurisdictions have banned the use of certain methods of 
paint removal, such as open flame burning, abrasive blasting, 
large scale dry scraping, and other methods known to produce 
high levels of contaminated dust and/or fumes.

Q.2. As I understand it, HUD's Lead Hazard Control Grants are 
awarded to cities on a competitive basis. Would it be a more 
effective use of Federal dollars to provide grants based upon 
the severity of lead poisoning, say targeting the top twenty 
cities with the most severe and widespread lead hazards?

A.2. Need, as documented by lead poisoning prevalence, is 
already a key factor used in making awards. The result is that 
HUD's grants are, in fact, targeted to local jurisdictions with 
the greatest problem. However, awarding grants based solely on 
need would have the unintended consequence of providing 
resources to some cities that lack the will or capacity to use 
them well. In fact, building capacity in numerous jurisdictions 
has enabled the program to address lead-based paint hazards in 
many more units than those it finances directly. Also, data 
from HUD's National Survey of Lead and Allergens in Housing 
show that urbanization is not a key factor in the prevalence of 
lead-based paint hazards, so restricting awards to larger 
cities ignores the need in other areas. In cities with 
populations above 2 million, 29 percent of the houses have 
lead-based paint hazards; in small cities, 23 percent have 
hazards; and in rural areas, 31 percent have hazards. None of 
these differences are statistically significant. To deny 
assistance to children simply because they do not reside in the 
largest cities raises issues of fairness and equity. HUD has 
considered whether the maximum amount requested by a 
jurisdiction should be equal or should be 
related to some combination of the number of poisoned children 
within a given jurisdiction and its capacity. The latter would 
increase the complexity of the program. This past year, HUD has 
implemented a new grant renewal system that streamlines the ap-
plication process for high-performing grantees, which are in 
areas of highest need as a further way of targeting resources. 
HUD will make a final decision regarding the maximum grant 
amount when the fiscal year 2003 Notice of Funding Availability 
is released.

         RESPONSE TO WRITTEN QUESTIONS OF SENATOR REED 
                   FROM THOMAS L. SANSONETTI

Q.1. How many lead cases do you currently have pending? Could 
you provide data on the number of cases referred by each Agency 
and the date these cases were referred? How many of these cases 
have DOJ chosen to prosecute?

A.1. We have 15 lead-paint related matters pending. Of the 15 
matters that are pending, 14 have been or are being jointly 
developed by Environmental Protection Agency (EPA) and Housing 
and Urban Development (HUD). The remaining matter is being 
developed by HUD, with anticipated participation by EPA at the 
appropriate time. We cannot meaningfully identify when each of 
these matters was referred because our initial involvement in 
these matters typically arose out of informal contacts with our 
Division over the course of time; formal referrals have then 
been submitted by the EPA and HUD following the informal contacts. 
We have not rejected any formal referrals.

Q.2. What statutory changes do you believe could be made to 
Federal disclosure law regarding lead-based paint and lead-
based hazards that could make it more meaningful?

A.2. Although the disclosure law provides for administrative 
penalties, it does not provide for judicial penalties. The 
addition of such penalties would strengthen enforcement of the 
law. Also the law currently excludes zero-bedroom housing from 
the disclosure requirements. Our experience has been that this 
excludes coverage for a significant portion of housing stock 
(that is studio apartments) in which poor children live and 
which contains lead-paint. Inclusion of such units in the 
disclosure law would better protect such children from the risk 
of lead poisoning.

Q.3. What plans does DOJ have to begin working more closely 
with other agencies such as HUD and EPA to help keep children 
from being poisoned by lead-based paint in housing?

A.3. As we testified at the June 5, 2002 hearing before the 
Subcommittee, we have already developed close working 
relationships with both HUD and the EPA and these relationships 
have resulted in a number of successful enforcement cases over 
the last 4 years. We look forward to continuing to work with 
them and also improving our outreach and training with the 
local U.S. Attorneys' Offices to protect children across the 
United States from lead poisoning.

Q.4. While abatement is essential in high-risk properties, in 
which cash flow is insufficient to support maintenance, most 
leaded properties can be made lead-safe through other 
strategies. Research and experience over the past decade has 
demonstrated the importance of visual inspection for peeling 
paint; lead-safe work practices to control, contain, and clean 
up lead dust in painting and remodeling projects; and clearance 
testing to ensure that lead-dust hazards are not left behind. 
Do you believe that visual inspection, lead-safe work practices 
and clearance testing offer the potential to expand lead-safety 
to a broad enough scale to make U.S. housing lead-safe?

A.4. We support the goal of preventing lead poisoning by making 
housing lead-safe, but respectfully defer to the expertise of 
our client agencies on how this can best be accomplished.

Q.5. While consistent data are not widely available, it is 
clear that in the majority of cases lead hazards are not 
corrected even after a child is identified as lead-poisoned. 
The same hazardous house often poisons multiple children as new 
families move in (that is, a Syracuse, New York, newspaper 
identified 47 houses that had poisoned multiple children in 
just 18 months). Even when health departments succeed in 
ordering repairs, in many States there is no oversight, no 
requirement for lead-safe work practices, and no clearance 
testing. While no house should poison a child, it is simply 
unconscionable that any house should poison a second, third, 
and fourth child. What do you believe your Agency can do to 
help stop houses from poisoning more than one child?

A.5. One significant way that the ENRD can help stop multiple 
children from being poisoned by the same property is by 
continuing to consider evidence of such a problem as a factor 
in enforcement decisions, that is in the decision of whether to 
pursue a matter criminally rather than (or in addition to) 
civilly, how much of a criminal fine or civil penalty to seek, 
and what other relief may be appropriate.

Q.6. What does your Agency believe might be appropriate 
statutory changes to make the Federal disclosure law regarding 
lead more meaningful?

A.6. See response to question 2.

Q.7. Many advocates and some health departments are convinced 
that ending childhood lead poisoning will require moving beyond 
screening children's blood-lead levels to actually screening 
high-risk housing to identify hazards before a child's health 
is harmed. What does your Agency think about this strategy? 
What about the idea of developing registries of hazardous 
properties?

A.7. We support the strategy of screening high-risk housing, 
and are already using it as an effective tool for identifying 
appropriate targets, for enforcement action. Depending on the 
information it contained, a registry of hazardous properties 
might assist us in targeting our enforcement efforts to where 
they would have the most impact.

Q.8. Does your Agency believe that lead-based paint and dust 
hazards in housing are the overwhelming cause of childhood lead 
poisoning in the United States? If not, what other causes 
should the Congress be looking at?

A.8. Based on information that we have received from those 
agencies that have expertise in this area, we believe that 
lead-based paint and dust hazards are the major cause of 
childhood lead poisoning in the United States.

Q.9. As a result of our hearing last November on lead 
poisoning, it was clear that primary prevention is a very 
important part of eliminating childhood lead poisoning. First 
of all, does your Agency support the goal of stopping children 
from being poisoned in the first place? If so, how is your 
Agency planning to achieve this goal?

A.9. Yes, we support the goal of stopping children from being 
poisoned in the first place. Working in concert with our 
clients at HUD and EPA and State and local health agencies, we 
plan to achieve this goal by deterring violations of the lead-
paint laws through continued vigorous enforcement of those laws 
and by seeking broad abatement that covers entire building 
inventories, not just an individual unit where disclosure 
wasn't made.

        RESPONSE TO WRITTEN QUESTION OF SENATOR CARPER 
                   FROM THOMAS L. SANSONETTI

Q.1. I understand that a student at Brown University performed 
a study that showed that 204 identifiable landlords owned the 
housing units which more than 2,600 cases of elevated blood-
lead levels were reported over the last 9 years in Rhode 
Island. This suggests that a small group of landlords are 
responsible for a disproportionate amount of the lead 
exposures. As you enforce lead disclosure laws, are you also 
coordinating with State or local departments of health so as to 
better target your enforcement?

A.1. Yes. As we testified in greater detail at the June 5, 2002 
hearing before the Subcommittee, State and local departments of 
health have been invaluable partners in our enforcement 
efforts.

         RESPONSE TO WRITTEN QUESTIONS OF SENATOR REED 
                        FROM ADAM SHARP

Q.1. Several years ago it became clear that clearance dust 
testing is a simple procedure that can be easily learned in one 
day. As a result, EPA developed a one-day training course for 
Sampling Technicians and HUD regs allow State certified sampling 
technicians to perform clearance testing after paint repair and 
remodeling projects. If the science makes clear the paramount 
dangers of lead-contaminated dust, why has EPA decided not to 
encourage expanded dust testing and expanding capacity for dust 
testing?

A.1. EPA does encourage expanded dust testing and increasing 
the number of individuals qualified to perform dust sampling. 
This policy was articulated to our State and Tribal colleagues 
in a letter dated August 17, 2000 (Attachment). The Agency 
stated that sampling technicians should play a principal role 
in conducting dust testing following nonabatement activities 
where lead-based paint is disturbed. In addition, the Agency 
encouraged the use of sampling technicians in other settings 
such as presale home inspections, unit turnovers, or at the 
request of homeowners. The letter also emphasizes that while 
EPA does not currently regulate nonabatement activities that 
disturb lead-based paint, the Agency does recommend dust 
testing (by a trained risk assessor, inspector, or Sampling 
Technician) following these activities. The Agency also 
encouraged States and Tribes to do the following:

 Allow Sampling Technicians to conduct nonabatement 
    clearance testing according to Housing and Urban 
    Development's (HUD) requirements.

 Permit trained and/or certified sampling technicians 
    to perform sampling to identify lead contaminated dust.

 Encourage accredited training programs to offer this 
    course.

 Develop a plan for upcoming legislative sessions that 
    would address the incorporation of the Sampling Technician 
    discipline in their authorizing legislation.

 Communicate regulatory policy regarding the use of 
    sampling technicians to their accredited trainers and 
    certified firms.

    In addition to these outreach activities, EPA will continue 
to emphasize the role of the sampling technician as we move 
forward with developing our renovation and remodeling program.

Q.2. Most Americans still view peeling paint in older housing 
as merely an eyesore and do not understand the significant 
danger of lead-contaminated dust. In January 2001, EPA 
finalized national standards for dangerous levels of lead in 
deteriorated lead-based paint, lead in dust, and lead in soil. 
What has EPA done to publicize these standards and highlight 
these dangers?

A.2. The Agency understands that to be effective, we must 
communicate the Agency's new lead hazard standards to the 
public. When the rule was released, the Agency launched its 403 
Rule Communication Plan, which consisted of the following:

 Press Release distribution and announcement on EPA's 
    website.

 Release and distribution of a 403 Rule Fact Sheet 
    through EPA's toll-free nationwide hotline and website.

 Notification of all other Federal agencies, and State 
    and tribal governments.

 Incorporation of the Hazard Standards in EPA's Protect 
    Your Family disclosure brochure, the most widely 
    distributed document (more than 500,000/yr.) in our 
    program.

 Education to EPA's hotline staff on the Hazard 
    Standards to better prepare them for public inquiries.

    Since the Rule was published, the Agency has been 
incorporating the standards into all of our public education 
materials. The first document that we revised was ``Protect 
Your Family From Lead,'' the Agency's main lead hazard 
pamphlet. This is the pamphlet required by law to be provided 
to buyers and lessors of all residential property built before 
1978. The Agency also requires that the pamphlet be distributed 
before most renovations in residential property built before 
1978. The EPA has incorporated the standards into our lead 
certification exams and will be formally updating our model 
training courses.

Q.3. Many researchers are convinced that EPA's standard for 
lead-contaminated dust of 40 micrograms per square foot is much 
too high. Has EPA analyzed any of those researchers' data yet?

A.3. Yes, the Agency continues to monitor the state of the 
science regarding environmental lead and its impact on 
children's health. In establishing the 40 micrograms per square 
foot dust standard, the Agency considered both the relationship 
between dust-lead and children's blood-lead levels and the 
health impacts associated with blood-lead levels. When we 
determined our standard, we considered the 10 ug/dl benchmark 
for elevated blood-lead levels currently defined by the Centers 
for Disease Control and Prevention. As far as the relationship 
between environmental lead and blood-lead, the Agency 
considered all of the studies of this relationship and 
continues to believe that the approach taken and the models 
used are the best currently available.

Q.4a. In 1998, HUD funded a survey conducted through the Bureau 
of the Census which showed poor compliance with the Residential 
Lead-Based Paint Real Estate Disclosure Rule, which mandates 
disclosure requirements for all sales and rentals of pre-1978 
housing. Thirty-six percent of survey respondents were 
uncertain whether they had received the required information 
when they bought or rented housing. What have you done to 
ensure that both buyers and renters are receiving the appropriate 
information as required by the Rule?

A.4a. To ensure widespread knowledge of the Rule requirements, 
EPA, in the development of the Rule, worked closely with HUD, 
realtors, real estate associations, property management 
companies, and landlord associations to publicize requirements 
through newsletters, meetings, pamphlets, public service 
announcements, and billboards. For example, EPA has:

 Worked with industry to include information on the 
    Disclosure Rule requirements in the real estate training 
    that real estate brokers need to complete as part of their 
    licences requirements.
 Undertaken mail-out campaigns to licenced real estate 
    operators to make them aware of the Rule.
 Attended national real estate meetings to train 
    people.
 Developed lead-paint websites to provide information 
    on rules and EPA regulations.

Q.4b. What additional ideas do you have to help protect 
families who are renting or buying housing and ensure that 
owners of housing are complying with this requirement?

A.4b. EPA has discussed several options, including expanding 
efforts to work with the real estate community through a 
sustained partnership. For families, the process of homebuying 
is complex, and lead is only one of many issues a family might 
consider when deciding where to live. For families in poor 
urban areas, where lead risks are greatest, competing interests 
(acute safety concerns) are even more pressing. In addition, in 
a tight housing market, many may feel that any apartment that 
they find will be good enough. That makes EPA's role in 
ensuring that lead issues are appropriately disclosed and 
considered even more challenging. We are considering multiple 
ways to meet this challenge, such as working with the real 
estate community to ensure that the information is disclosed in 
a way that will be most meaningful to the recipient, working 
with other parts of the housing industry (home inspectors, 
etc.) to encourage them to broadly distribute and reinforce 
this information, and working with organizations involved in 
low-income housing to address lead issues in a holistic 
fashion.

Q.5. What has been EPA's lead poisoning prevention funding over 
the past 5 years? Is this amount of funding sufficient for EPA 
to be an active participant in eliminating lead poisoning by 
2010?

A.5. Over the past 5 years, EPA has committed more than $169 
million to its lead poisoning prevention program. More than $80 
million of these funds have been distributed to States, Tribes, 
and U.S. Territories to assist them in establishing and 
administering their own lead poisoning prevention programs. 
This level of funding is sufficient to ensure that we are an 
active participant in the Federal Governments efforts to 
eliminating lead poisoning.

Q.6. Your testimony talks about the 1996 Rule covering training 
and certification for lead-based paint professionals. How many 
people have been trained since the Rule was passed? Are there 
enough trained professionals to meet the need? What efforts has 
EPA been engaged in to increase participation beyond the 35 
States who have obtained training grants and what tools might 
be needed to help achieve this goal?

A.6. In 1996, EPA issued a regulation to establish a nationwide 
network of trained and certified lead professionals. Since 
then, we have authorized 34 States, three Tribes, Puerto Rico, 
and the District of Columbia to administer and enforce this 
program. EPA is running the program in all nonauthorized States 
and Tribal lands.

    EPA estimates that to date there have been more than 20,000 
individuals certified by either EPA or our authorized State 
partners to identify and abate lead hazards. We believe that on 
a national basis, there are a sufficient number of certified 
individuals. Admittedly, in certain regions of the country, 
there are fewer certified contractors than we would like to 
see. For our part, EPA is constantly refining and updating our 
certification and accreditation systems to make them more 
responsive to the needs of the regulated community. For 
example, within a year, individuals seeking certification will 
have the ability to pay online via credit card and submit their 
application forms online.

    With respect to the number of authorized programs, EPA is 
pleased with the fact that we have authorized as many States 
and Tribes as we have. The Agency has always believed that this 
program is best administered at the local level. We continue to 
encourage unauthorized States and Tribes to develop programs, 
and we provide technical and financial assistance to any State 
or Tribe that wishes to seek authorization. At the same time, 
we recognize that financial considerations often determine 
whether a State or Tribe seeks authorization. We will continue 
to solicit input from the States and Tribes so that future 
regulatory elements of the program create incentives to State 
and Tribal authorization. EPA is more than capable of 
administering and enforcing this program in the States and 
Tribes that have chosen not seek authorization.

Q.7. Your testimony states that parents have greatly helped to 
reduce lead exposure to their children by cleaning and 
maintaining homes. Do you have any specific data highlighting 
the positive effects of these efforts?

A.7. Results from studies of educational interventions and 
cleaning by residents show that there is evidence that cleaning 
by residents can reduce lead levels. In an East St. Louis, 
Illinois study, 50 percent declines in dust-lead levels were 
reported in the 44 percent of the homes where the family 
reported that cleaning had been done according to instruction. 
In a study in Boston, Massachusetts, a 36 percent decline in 
blood-lead levels and a 38 percent decline in window sill lead 
levels were reported for a control group that received an 
outreach visit, cleaning instructions, and a free sample of 
cleaning solutions. In this study, floor and window well levels 
were essentially unchanged. In a study in Rochester, New York, 
30-60 percent declines in most surfaces were reported following 
cleaning, but blood-lead levels did not decrease. Blood-lead 
levels decreased by 15 percent in a Milwaukee, Wisconsin study 
of educational interventions that included a demonstration of 
clean up and maintenance measures by outreach workers. 
Additional information on the effectiveness of lead 
interventions and abatement in residential housing can be found 
in the EPA report, ``Review of Studies Addressing Lead 
Abatement Effectiveness: Updated Edition'' (EPA 747-B-98-001, 
December 1998). This report is available through the Internet 
at the URL: http://www.epa.gov/lead/finalreport.pdf

    There has been a decline in children's blood-lead levels 
from 1976 to 1999 that coincides with efforts by the Federal 
Government and other parties to reduce exposure to lead and to 
increase the public's awareness of the dangers of lead. 
Specifically, the geometric mean blood-lead level for children 
aged 1-5 years was 18.0 micrograms per deciliter ( g/dL) in 
1976 based on data collected in the National Human Health and 
Exposure Study II (NHANES II). By 1980, the geometric mean 
level for this group of children had declined to 9.3  g/dL, 
again based on data from NHANES II. The trend of declining 
geometric means continued in the late 1980's and in the 1990's. 
The geometric mean blood-lead level for children aged 1-5 years 
was 3.6  g/dL for the period 1988 to 1991, as reported from 
NHANES III Phase 1. For the period 1991 to 1994, the geometric 
mean for this group of children was 2.7  g/dL from NHANES III 
Phase 2. NHANES 1999, which was based on a smaller size sample 
than previous NHANES studies, estimated the geometric mean to 
be 2.0  g/dL. In addition, when the 1999 NHANES geometric mean 
was published, CDC published statistics based on data from 19 
States with blood surveillance programs. These statistics 
showed that the proportion of children less than 6 years old 
with elevated blood-lead levels declined in the period from 
1996 to 1999 in this group of States.

Q.8. Your testimony discusses the National Lead Awareness 
Campaign. Please describe the program and its positive effects. 
What is the current status of the program?

A.8. The EPA's National Lead Awareness Program has five 
components. They are:

 Targeting high-risk communities.

 Having material available in languages other than 
    English.

 Working extensively and cooperatively with other 
    Federal partners such as CDC, HUD, USDA, and the 
    Administration of Children and Families (HHS).

 Funding community-based organizations to provide 
    education at the grass roots level.

 Developing culturally-sensitive materials particularly 
    for Native Americans.

    The program has taken several steps to ensure a positive 
impact on the populations most at-risk. Two years ago, EPA 
launched the ``Runs Better Unleaded'' campaign featuring 
posters, mass transit, billboard, and movie theater 
advertising, and radio public service announcements. The 
campaign, designed to raise awareness, received an award from 
the International Association of Business Communicators, and 
has been replicated in several cities and States.

    Over the past 2 years, EPA has developed a WIC (Women, 
Infants, and Children Program) Nutritionist Educational 
Campaign. The initiative is more focused than previous efforts 
because it targets WIC's seven million clients and the staff 
they rely on for nutritional and general health information. 
The materials were created in cooperation with the CDC and 
USDA/WIC staff at the national, State, and local levels. The 
materials are designed to help the nutritionists get out the 
message of testing children and their homes for lead, and to 
highlight the lead poisoning/nutrition connection. The 
cornerstone of this effort, EPA's ``Fight Lead Poisoning With a 
Healthy Diet'' brochure, provides not only prevention and 
detection messages, but also WIC-approved recipes. A Spanish-
language version is currently being printed. EPA also developed 
a Media Outreach Kit, an adaptable guide for State and local 
health, housing, and environmental programs to assist them in 
working with the press to get information out about lead 
poisoning prevention. Updates to this guide are available in 
CD-ROM format and on EPA's website.

    Currently EPA is developing an outreach initiative with the 
Head Start program to provide educational materials and empower 
this high-risk population. Specifically, we will share 
information with Head Start educators and the children's 
parents on the health hazards of lead-based paint, lead's 
deleterious developmental 
effects, and how to avoid these problems.

Q.9a. Your testimony talks about cooperative programs with 
retail stores to distribute materials, and partnership programs 
with nonprofits and other agencies. Do you believe that these 
efforts are enough to spread the word about the dangers of 
peeling paint and paint dust?

A.9a. EPA has partnered with several organizations to provide 
outreach and education to the public on the dangers of lead-
based paint hazards. However, EPA believes that its lead 
outreach activities should be continuous and has planned 
several future efforts. In particular, our planned Renovation 
and Remodeling Outreach Campaign will spread the messages of 
lead-safe work practices and training possibilities directly to 
contractors who do the work, nonprofits who support the various 
industries that work with lead, and the owners of homes who 
would benefit from lead-safe housing. A sustained, 
multifaceted, multimedia approach is key to not only getting 
the public aware of lead issues, but also to get them to take 
action to prevent lead poisoning.

Q.9b. The Task Force recommended an expansion of these efforts, 
what have you done to increase outreach?

A.9b. EPA has been involved in several outreach efforts, as 
well as having many planned for the future including: (1) 
participating in the ``National Lead Poisoning Prevention 
Week.'' This includes partnering with Centers for Disease 
Control and Prevention, Department of Housing and Urban 
Development, and the District of Columbia Health Department; 
(2) working with the Department of Agriculture's Women, 
Infants, and Children (WIC) Program to develop and distribute 
fact sheets and the document ``Fight Lead Poisoning With a 
Healthy Diet,'' which links nutrition and lead prevention; (3) 
partnering with the Centers for Disease Control and Prevention, 
Department of Housing and Urban Development, and the Agency for 
Disease Registry and Toxic Substances to cosponsor a national 
lead health education conference with representatives from 
Federal, State, and Tribal governments; (4) working with a 
national community-based volunteer organization, Hope For Kids, 
to educate parents in several cities across the United States 
on lead poisoning prevention; (5) working with the Department 
of Justice's Weed and Seed Program, a national community 
organization that focuses on keeping juveniles out of the 
justice system, to educate parents and community members on 
lead poisoning prevention; (6) providing a grant for the 
development and distribution of Spanish-language public service 
announcements; and (7) establishing Tribal lead outreach 
campaigns and blood-lead screening of Tribal children.

Q.9c. How much money has been spent on this effort?

A.9c. EPA has committed nearly $4 million to this effort.

Q.9d. What additional ideas does EPA have that might help 
increase public awareness of lead-based paint hazards in the 
home?

A.9d. General awareness messages of the past have been 
successful, but more can be done to target the most at-risk 
populations, often low-income, minority children living in 
older urban housing. Whether it is to motivate a parent to get 
their child tested, a property owner to get his rental property 
inspected, or a contractor to take proper health-protection 
steps, EPA is always looking for the best way to approach those 
most in need of our information. We are providing more 
resources electronically through EPA's website and the National 
Lead Information Center. However, EPA realizes that the most 
vulnerable communities may not have Internet access, and to 
that end, we continue to produce hard copies of our educational 
materials. EPA also plans to continue its partnerships with 
nonprofit organizations that serve those populations. Through 
these partners, we learn more about our audiences and adjust 
our efforts accordingly.

    ``Do-it-yourselfers,'' homeowners that perform renovations 
in their own properties, are a group that may damage not only 
their own health, but also the health of any children and 
families that live in their properties. Due to the potential 
for increased lead exposure, we are discussing an educational 
outreach plan to promote lead-safe activities by these owners.

Q.10. How many cases have been referred to DOJ in the last year 
and a half ? What is the status of those cases?

A.10. During the last year and a half, EPA has referred a dozen 
cases to the U.S. Department of Justice for civil judicial 
enforcement: Six for injunctive relief for Section 1018 (Lead 
Disclosure Rule) violations, and six for judicial enforcement 
subpoenas under the Toxic Substances Control Act (TSCA). Eleven 
of these cases have been resolved in the United States' favor. 
The three biggest injunctive relief settlements required 
inspections, risk assessments and remediation of the lead-based 
paint hazards for 13,000 dwelling units in Chicago and 
Cincinnati. One TSCA subpoena case is currently pending in the 
U.S. District Court for Rhode Island. In addition, EPA has also 
issued more than 50 civil administrative complaints with 
proposed monetary penalties over this time period. In one 
administrative settlement, a property management firm agreed to 
conduct inspections, risk assessments, and lead-based paint 
hazard remediation in 132,000 dwelling units nationwide.

Q.11. While abatement is essential in high-risk properties, in 
which cash flow is insufficient to support maintenance, most 
leaded properties can be made lead-safe through other 
strategies. Research and experience over the past decade has 
demonstrated the importance of visual inspection for peeling 
paint; lead-safe work practices to control, contain, and clean 
up lead dust in painting and remodeling projects; and clearance 
testing to ensure that lead dust hazards are not left behind. 
Do you believe that visual inspection, lead-safe work 
practices, and clearance testing offer the potential to expand 
lead-safety to a broad enough scale to make U.S. housing lead-
safe?

A.11. This approach has the potential to expand lead-safety to 
make many more homes lead-safe. Visual inspection and the 
prompt lead-safe repair of deteriorated lead-based paint can 
reduce the number of homes in this country with existing paint 
lead hazards.

    Pursuant to the direction of Title X, the EPA is developing 
a program to introduce lead-safe work practices in the 
renovation and remodeling industry. Through education and 
outreach and regulation, the Agency hopes to increase the use 
of these practices during renovations in homes with lead-based 
paint to prevent the introduction of new hazards. This program 
can also be used to reduce existing paint lead hazards in homes 
that are unlikely to be abated.

    Clearance testing is still the best indicator to ensure 
that dust-lead hazards do not remain after an abatement or 
renovation event. EPA is evaluating a range of regulatory and 
technical alternatives to make dust clearance testing even more 
affordable and widely available.

Q.12. While consistent data are not widely available, it is 
clear that in the majority of cases lead hazards are not 
corrected even after a child is identified as lead-poisoned. 
The same hazardous house often poisons multiple children as new 
families move in (that is, a Syracuse, New York, newspaper 
identified 47 houses that has poisoned multiple children in 
just 18 months). Even when health departments succeed in 
ordering repairs, in many States there is no oversight, no 
requirement for lead-safe work practices and no clearance 
testing. While no house should poison a child, it is simply 
unconscionable that any house should poison a second, third, 
and fourth child. What do you believe your Agency can do to 
help stop houses from poisoning more than one child?

A.12. Once a house has been determined to be the cause of a 
child's lead poisoning, the hazards should be addressed to 
ensure that the house does not poison other children. EPA 
regulations clearly state that when work is done to eliminate 
lead hazards due to the presence of a lead-poisoned child, the 
work must be done following EPA abatement regulations, 
including requirements for lead-safe work practices and 
clearance testing. The EPA has authority over such actions in 
all nonauthorized States and Tribes. In authorized States and 
Tribal lands, equally protective State or Tribal regulations 
would apply.

    However, EPA itself has no general authority to order 
abatements, or to ensure that abatements ordered by State 
health departments are actually carried out. EPA authority 
begins once an abatement activity begins. Therefore, while EPA 
can ensure that abatement, when performed, is performed 
correctly, we cannot force abatements to be performed in the 
first place.

    EPA is able to encourage abatement and other lead hazard 
control activities as part of settling administrative and 
judicial enforcement cases for violations of the Lead 
Disclosure Rule requirements. EPA enforcement settlements have 
resulted in over 150,000 housing units becoming lead-safe, as 
defined under the HUD guidelines. EPA intends to continue to 
encourage landlords and property managers to review their 
compliance with the Lead Disclosure Rule and to conduct lead 
abatement activities in settling enforcement 
actions to address lead-paint hazards. Also, settlements have 
included projects aimed at reducing the future risk of harm 
from lead-based paint. For example, violators have funded 
clinical blood-lead testing of children and pregnant women at 
risk for lead-paint poison, and funded a seminar on the Lead 
Disclosure Rule requirements for real estate agents and 
brokers.

    In individual, extreme cases, EPA has authority under the 
Resource Conservation and Recovery Act (RCRA) to address 
imminent and substantial endangerment arising from lead-based 
paint. Under RCRA, Section 7003, EPA can order property owners 
to take immediate action to minimize lead exposure to tenants, 
including removing lead-based paint and paint wastes, if EPA 
has determined that the tenants may be in imminent and 
substantial danger of lead poisoning.

Q.13. What does your Agency believe might be appropriate 
statutory changes to make the Federal disclosure law regarding 
lead more meaningful?

A.13. EPA does not believe that any statutory changes to 
Section 1018 are needed. Our continuing enforcement actions 
coupled with our outreach efforts are accomplishing the goal of 
informing the public so that they can take appropriate actions.

Q.14. Many advocates and some health departments are convinced 
that ending childhood lead poisoning will require moving beyond 
screening children's blood-lead levels to actually screening 
high-risk housing to identify hazards before a child's health 
is harmed. What does your Agency think about this strategy? 
What about the idea of developing registries of hazardous 
properties?

A.14. One key benefit of EPA's lead hazard standards is to 
enable exactly what you are suggesting--to screen housing for 
hazards before children are poisoned. These protective, health-
based standards provide a criterion to identify this high-risk 
housing. Our real estate disclosure regulations also support 
this strategy by providing prospective tenants and buyers the 
opportunity to uncover hazards or potential hazards before 
moving into a dwelling.

    EPA has not analyzed how such a registry program would 
work. Nevertheless, EPA is considering establishing a program 
to encourage landlords to maintain their buildings in a lead-
safe manner, and then to recognize and publicize their efforts. 
We believe this approach may have a better chance of 
accomplishing our goal, because we can highlight lead-safe 
properties for the consumer, and we hope to also have landlords 
formally agree to long-term maintenance of their buildings in 
order to participate.

Q.15. Does your Agency believe that lead-based paint and dust 
hazards in housing are the overwhelming cause of childhood lead 
poisoning in the United States? If not, what other causes 
should Congress be looking at?

A.15. Yes, the Agency continues to believe that lead-based 
paint and dust hazards in housing are the primary sources of 
lead exposure for most children. Certainly, multiple other 
sources of lead exist (folk remedies, consumer goods, etc.) and 
may be responsible for individual cases of lead poisoning, but 
housing-related sources are by far the predominant cause of 
lead poisoning in the United States today.

Q.16. As a result of our hearing last November on lead 
poisoning, it was clear that primary prevention is an extremely 
important part of eliminating childhood lead poisoning. First 
of all, does your Agency support the goal of stopping children 
from being poisoned in the first place? If so, how is your 
Agency planning to achieve this goal?

A.16. Yes, EPA, for years, has unequivocally supported the goal 
of primary prevention. We plan to achieve this goal via many 
routes. Our regulatory program is designed to provide criteria 
for identifying lead hazards to give consumers the knowledge 
and tools to address lead hazards before their children are 
poisoned, and to have qualified people available to identify 
and fix lead hazards. Our public education program is designed 
to reach people most at risk, at points in their life where 
they can most easily take action to prevent lead poisoning, 
rather than simply providing information after the damage has 
been done. One key goal of our technical program is to lower 
the cost of lead hazard assessment and repair activities, to 
encourage more people to use these services. We hope that we 
are already seeing the fruits of our labors by the continuing 
decline in the numbers of lead-poisoned children.







         RESPONSE TO WRITTEN QUESTIONS OF SENATOR REED 
                   FROM RUBEN KING-SHAW, JR.

Q.1. States like Alaska have long argued they should be excused 
from universal screening because they believe they have low 
lead concentrations. Have these States presented any data, 
either in terms of their housing stock or screening rates for 
Medicaid-eligible children that would substantiate their 
position?

A.1. The States of Alaska and Utah have both submitted material 
that they suggest supports discontinuing universal lead 
screening for all Medicaid eligible children in their State. 
This material was submitted in 1998 and CMS (then HCFA) was not 
in a position at that time to consider allowing States to 
discontinue universal screening. However, we reviewed the 
information from both the States and informed them of our 
conclusions as follows:
    We reviewed the study and data submitted by Alaska and 
concluded that it was insufficient to be used to allow the 
State to discontinue universal screening based on several 
drawbacks of their study. For example, while the study was 
well-designed, there was a very low response rate from a 
particular group (urban respondents) and this made data 
comparisons difficult. Another limitation was that the State 
tested children between the ages of 1 and 6 but did not include 
children under the age of one from the study. We believe the 
State should have attempted to obtain data on this age group, 
either by looking at Medicaid claims or pediatrician records, 
since the State felt performing the venipuncture on these young 
children was too difficult.
    The State of Utah submitted a study from Salt Lake County 
that was performed by offering blood-lead tests to families 
enrolled in the WIC Program. The study data was collected from 
seven WIC clinics dispersed throughout Salt Lake County. In 
this instance we felt the study was too limited to be able to 
make a statewide recommendation.

Q.2a. The 1999 GAO report on the lead poisoning prevention 
efforts at Federal health care programs pointed out several 
deficiencies, including the fact that only 20 percent of 
Medicaid-eligible children are currently screened for lead 
poisoning. In your testimony, you noted that CMS sent letters 
to all State Medicaid directors detailing the findings of the 
GAO report and reiterating their responsibilities with regard 
to lead screening. Has CMS taken any other definitive action to 
address these problems?

A.2a. CMS has continued to work on the lead screening issue 
since the GAO report. In April 2000, CMS, the Centers for 
Disease Control and Prevention (CDC), the Health Resources and 
Services Administration (HRSA), and the Administration for 
Children and Families (ACF) cosigned a letter to State Medicaid 
Directors, CDC grantees, Head Start programs, and numerous 
other ACF and HRSA contacts transmitting our October 1999 State 
Medicaid Director letter and information on CMS' strategy for 
assuring that States comply with our lead screening policy. We 
also encouraged States to work together at the State and local 
level as we were doing at the Federal level.
    CMS currently participates on the CDC's Advisory Committee 
for Childhood Lead Poisoning Prevention as an ex-officio Member 
of the Committee. CMS has been extensively involved in the 
Committee's work and deliberations related to lead screening of 
Medicaid children and other aspects related to lead poisoning 
of Medicaid children. In December 2000, the Committee published 
``Recom-
mendations for Blood Lead Screening of Young Children Enrolled 
in Medicaid: Targeting a Group at High Risk.'' Currently the 
Committee is developing a report to Secretary Thompson 
recommending ways that State Medicaid agencies can target lead 
screening to those Medicaid children at highest risk for lead 
poisoning.
    CMS also participates with many other Federal agencies on 
the President's Task Force on Environmental Health Risks and 
Safety Risks to Children. In February 2000, the Task Force 
published ``Eliminating Childhood Lead Poisoning: A Federal 
Strategy Targeting Lead Paint Hazards.'' The report presents a 
program for eliminating childhood lead poisoning by 2010 based 
on coordinating the efforts of various Federal agencies 
including the Department of Housing and Urban Development 
(HUD), the Environmental Protection Agency (EPA), CDC, and CMS. 
The report identified the 
efforts and activities undertaken by CMS since the publication 
of the 1999 GAO study on lead poisoning to improve the 
screening, diagnosis, and treatment of Medicaid children with 
lead poisoning. The report also highlighted the work of an 
interdepartmental work group consisting of CMS, CDC, HRSA, and 
other DHHS agencies to improve access and the provision of 
these services.
    CMS will continue to play a major role in Federal 
activities designed to reduce and eliminate lead poisoning of 
young children in this country. CMS' particular focus is in 
covering the secondary and tertiary preventive services needed 
by Medicaid children (for example, screening, diagnosis, and 
treatment services). Probably the most effective strategy we 
can employ is to encourage our State Medicaid agencies/partners 
to work together with their local health, housing, and 
environmental agencies toward the common goal of eliminating 
lead poisoning.
    We have awarded two contracts that we believe will assist 
in improving screening rates. The contract with the Alliance to 
End Childhood Lead Poisoning resulted in an outreach and 
educational document for States to assist them in dealing with 
providers and managed care organizations. The final document 
from the Alliance contract published in August 2001, Track, 
Monitor and Respond: Three Keys to Better Lead Screening for 
Children in Medicaid, is intended to be an educational document 
that States can use in their outreach to their providers in 
order to resolve some of the difficulties in the provision of 
the blood-lead screening tests. The second contract with Abt 
Associates is expected to produce a final report providing us 
with good information and key elements for screening the 
highest risk children. The Abt Associates final report will 
also shed more light on how State Medicaid agencies are 
successfully working with other State and local agencies to 
address this problem. We intend to share this information with 
State Medicaid agencies.
    We continue to encourage State Medicaid agencies to 
participate in data sharing activities so that the health 
department and the Medicaid Agency know which Medicaid eligible 
children have been tested and which have not. We do know that 
many States are beginning to work on these data sharing 
agreements.

Q.2b. If not, what tools or authority does CMS need to help it 
remedy these deficiencies and ensure that Federal law is being 
followed?

A.2b. We continue to work with the States and other Federal 
agencies such as CDC on this issue and believe that this is the 
best way to continue addressing the problems. We hope to 
distribute the final report from the Abt contract to all States 
to provide them with information on what has worked, or has not 
worked, in other States. We believe sharing information is one 
of the best ways to encourage States to continue to focus on 
this important issue.
    While our only enforcement tool against States is to take a 
compliance action that could result in the withholding of 
Federal Financial Participation (FFP), we do not believe 
withholding money from the entire program is a practical or 
effective approach to the problem. Additionally, the compliance 
process is a lengthy ordeal that can take years to complete. 
CMS has never withheld monies from a State as a result of a 
compliance action.

Q.2c. In addition, what additional enforcement powers may be 
helpful to CMS to ensure that managed care companies that are 
not performing screening comply with their contract 
requirements?

A.2c. The States monitor managed care organization (MCO) 
performance through their contracts, and the MCO's report lead 
screenings to the State, which then includes them in the 
State's report to us.
    Interestingly, in the managed care arena there is more 
accountability than in fee-for-service because the State has 
the ability to hold the MCO accountable through the contract, 
whereas in FFS it is very difficult to hold all providers 
accountable. An increasing number of States are incorporating 
into their contracts with MCO's specific language and 
requirements pertaining to lead screening. A 1999 study found 
that 42 percent of Medicaid MCO's contracts had specific lead-
screening requirements. More recently, George Washington 
University developed under contract with the CDC sample 
purchasing specifications for use by States in their contracts 
with Medicaid MCO's. Sample specifications for lead poisoning 
prevention were developed in this process. A number of States 
also require their Medicaid managed care contractors to report 
lead screening as part of their Health Plan Employer Data and 
Information Set (HPEDIS) performance measures.

Q.3. As we heard during testimony, the cause of the vast 
majority of lead poisoning in the United States is the home 
environment. For this reason, Medicaid allows States to cover 
the cost of a one-time environmental assessment of the home. 
However, Medicaid will not pay for testing of the dust, soil, 
or water at the house as part of this assessment. Could you 
please explain to the Committee the rationale behind Medicaid's 
policy? Would CMS support changing this policy so that Medicaid 
could pay for the testing of dust and other samples in the 
homes of lead-poisoned children?

A.3. The role of Medicaid is to reimburse for the delivery of 
medical services directly to eligible individuals. Using 
Medicaid funds to do other environmental remediation is beyond 
the bounds of Medicaid and would not be an appropriate use of 
these funds. Extending coverage under Medicaid to other 
environmental interventions such as testing of environmental 
substances would have tremendous im-
plications for State and Federal Medicaid budgets. Therefore, 
we would not support a change in this policy.
    One factor that impacts this decision is that under the 
Medicaid program, laboratory tests must be performed in CLIA 
certified laboratories. CLIA certified laboratories are only 
certified to perform testing on human specimens. This 
requirement is stated in the statutory language in the Public 
Health Act, as well as CMS' regulations. Testing of 
environmental specimens is not performed in CLIA certified 
labs. Therefore, we cannot pay for these types of laboratory 
tests under the current law.
    Even if it were possible to pay for environmental testing 
for lead under another coverage category, it would be extremely 
difficult to limit this coverage to only lead, absent specific 
legislative authority. There are many other diseases and 
conditions that are affected by environmental conditions in the 
home, for example, asthma. We, as well as States, would be put 
under pressure to then begin reimbursing for these other types 
of environmental interventions such as air filters or special 
bedding.
    Housing agencies, as well as homeowners and landlords need 
to be responsible for their dwellings. Medicaid funds should be 
used for medical services to screen, diagnose, and treat lead-
poisoned children. Our other partners in this area, such as 
HUD, and State and local governments, are better situated to 
address the housing issue.

Q.4. In your written testimony, you discuss a cooperative 
agreement between CMS and the Alliance to End Childhood Lead 
Poisoning to develop an educational guide to improve awareness 
of and compliance with CMS' policies. It is my understanding 
that the original $250,000 agreement was funded by the previous 
Administration. When the Alliance submitted a proposal to 
extend this valuable outreach program an additional 18-months, 
CMS denied the request, despite report language in the fiscal 
year 2002 Labor-HHS-Education Appropriations bill encouraging 
CMS to support outreach and education. What was the reason for 
CMS' turnaround in supporting this cooperative agreement with 
the Alliance? What is CMS currently doing to support outreach 
and education as encouraged in the fiscal year 2002 
Appropriations bill?

A.4. When the Alliance's unsolicited proposal was received in 
2000, the Senate and House Appropriations Report recommended 
that CMS take appropriate steps to ensure that screening rates 
among children enrolled in Medicaid substantially increase. At 
that time, CMS had some discretionary funds available for this 
type of project. Therefore, we funded the Alliance $250,000 for 
the education and outreach project and also awarded a contract 
to Abt Associates for approximately $750,000 for an additional 
study on lead screening activities. At the time the Alliance 
requested additional funding, CMS was unable to accommodate 
this request due to the lack of additional discretionary funds. 
This funding situation has not changed.

Q.5a. You also describe in your testimony a study your Agency 
has commissioned to improve the lead screening of low-income 
children by assessing the impact and effectiveness of current 
screening criteria in reaching high-risk, low-income children. 
While I applaud the Agency for its continued work to ensure 
that screening criteria are appropriately targeting those 
children at greatest risk of lead exposure, I am concerned that 
this might mean the bigger picture is being missed. Could you 
please describe for the Subcommittee what specific steps or 
actions CMS is taking to ensure that all States are meeting the 
blood-lead screening requirement under the EPSDT benefit for 
Medicaid-eligible children?

A.5a. The latest data that we have from our CMS-416 EPSDT 
report indicates that nationally about 60 percent of Medicaid 
children under 21 are receiving all of the age-appropriate 
medical screening services. Unfortunately, the data on lead 
screening reported on the CMS-416 since fiscal year 1999 
continues to be problematic. However, CMS is actively involved 
in collaborating and working with our State partners to improve 
compliance through conferences, meetings, technical assistance 
sessions, and work groups and dissemination of materials 
including ``State best practices'' produced with Federal funds. 
We feel that we will be more successful through these 
collaborative activities rather than taking punitive action 
against the States.
    We also believe the two contracts we have undertaken, with 
the Alliance to End Childhood Lead Poisoning and Abt 
Associates, will assist us in improving screening rates. The 
Alliance contract has provided an outreach and educational 
document to States to assist them in dealing with the providers 
and managed care organizations. We also expect the final 
product from the Abt contract to provide us with some good 
information of successful programs States have implemented to 
improve their screening rates.

Q.5b. What is CMS doing to encourage States to take creative 
approaches to lead poisoning prevention and detection, such as 
my home State of Rhode Island, which received a waiver to use 
Medicaid funds to pay for window replacements in homes where 
lead-poisoned children reside?

A.5b. We encourage States to be innovative in their approach to 
the lead screening issue. We believe the Abt study will 
highlight some of these innovations and we will share that 
information with all the State Medicaid agencies. In the case 
of Rhode Island, the State already had an approved statewide, 
comprehensive section 1115 demonstration to expand Medicaid 
eligibility within a managed care delivery system. The 
amendment to include the window replacement was in the context 
of the larger demonstration project but targeted to expand the 
effectiveness of an ongoing State effort using lead centers. 
Through the comprehensive demonstration the State is able to 
achieve the savings necessary to make the lead amendment budget 
neutral. Achieving such budget neutrality absent a 
comprehensive demonstration would be very difficult. However, 
CMS is willing to review any innovative State proposals using 
this approach.

Q.5c. What can be done to change the perception among health 
care providers that lead poisoning screening is not necessary 
and important?

A.5c. I do not think the issue is one of perception of 
importance but rather of risk of exposure based on one's 
professional judgment. The final document from our Alliance to 
End Childhood Lead Poisoning contract, Track, Monitor and 
Respond: Three Keys to Better Lead Screening for Children in 
Medicaid, was intended to be an educational document that 
States could use in their outreach to their providers in order 
to resolve some of the difficulties in the provision of the 
blood-lead screening tests.
    We hope that the final Abt Associates product will also 
shed more light on how State Medicaid agencies are successfully 
working with other State and local agencies to screen the 
highest risk children, including provider groups and managed 
care organizations. National provider organizations could also 
be encouraged to remind their members about the importance of 
lead screening.

Q.6. While abatement is essential in high-risk properties, in 
which cash flow is insufficient to support maintenance, most 
leaded properties can be made lead-safe through other 
strategies. Research and experience over the past decade has 
demonstrated the importance of visual inspection for peeling 
paint; lead-safe work practices to control, contain, and clean 
up lead dust in painting and remodeling projects; and clearance 
testing to ensure that lead dust hazards are not left behind. 
Do you believe that visual inspection, lead-safe work 
practices, and clearance testing offer the potential to expand 
lead-safety to a broad enough scale to make U.S. housing lead-
safe?

A.6. The Federal Medicaid program makes funding available for a 
one-time investigation to determine the source of lead. We 
believe this inspection is an important first step to making 
many houses lead-safe. However, the other issues raised here, 
lead-safe work practices and clearance testing, are beyond the 
purview of the Medicaid program. Other Federal agencies such as 
CDC, HUD, and EPA are better suited to addressing the importance 
of these practices.

Q.7. While consistent data are not widely available, it is 
clear that in the majority of cases, lead hazards are not 
corrected even after a child is identified as lead-poisoned. 
The same hazardous house often poisons multiple children as new 
families move in (that is, a Syracuse, New York, newspaper 
identified 47 houses that had poisoned multiple children in 
just 18 months). Even when health departments succeed in 
ordering repairs, in many States there is no oversight, no 
requirement for lead-safe work practices, and no clearance 
testing. While no house should poison a child, it is simply 
unconscionable that any house should poison a second, third, 
and fourth child. What do you believe your Agency can do to 
help stop houses from poisoning more than one child?

A.7. The role of Medicaid is to reimburse for the delivery of 
medical services directly to eligible individuals. Using 
Medicaid funds to do lead abatement or any other environmental 
remediation is beyond the bounds of Medicaid and would not be 
an appropriate use of these funds. Extending coverage under 
Medicaid to lead abatement and other environmental 
interventions would have tremendous implications for State and 
Federal Medicaid budgets. However, as stated earlier, Medicaid 
does reimburse for a one-time investigation to determine the 
source of lead. This includes the time and activities of a 
health professional to visit the home of a Medicaid eligible 
child with an elevated blood-lead level to help determine the 
source of lead poisoning.
    Housing agencies, as well as homeowners and landlords need 
to be responsible for their dwellings. Medicaid funds should be 
used for medical services to screen, diagnose, and treat lead-
poisoned children. Our other partners in this area, such as 
HUD, and State and local governments, are better situated to 
address the housing issue.

Q.8. What does your Agency believe might be appropriate 
statutory changes to make the Federal disclosure law regarding 
lead more meaningful?

A.8. The Federal Medicaid program has no authority to enforce 
nor interpret the Federal disclosure law. We believe this 
question is more appropriately directed to the HUD.

Q.9. Many advocates and some health departments are convinced 
that ending childhood lead poisoning will require moving beyond 
screening children's blood-lead levels to actually screening 
high-risk housing to identify hazards before a child's health 
is harmed. What does your Agency think about this strategy? 
What about the idea of developing registries of hazardous 
properties?

A.9. We believe that CDC and State and local governments have 
indeed compiled a great deal of data regarding hazardous 
housing. CDC would be a better source of identifying what gaps 
remain.

Q.10. Does your Agency believe that lead-based paint and dust 
hazards in housing are the overwhelming cause of childhood lead 
poisoning in the United States? If not, what other causes 
should 
the Congress be looking at?

A.10. CMS relies on the CDC for its information and 
recommendations on lead screening. We believe CDC along with 
HUD and EPA may have additional ideas on what, if any, other 
hazards that Congress could address.

Q.11. As a result of our hearing last November on lead 
poisoning, it was clear that primary prevention is an extremely 
important part of eliminating this childhood lead poisoning. 
First of all, does your Agency support the goal of stopping 
children from being poisoned in the first place? If so, how is 
your Agency planning to achieve this goal?

A.11. CMS does support the goal of preventing children from 
being poisoned by lead in their environment. However, due to 
the statutory requirements of our program that direct our 
funding be used for medical purposes, we are unable to focus 
our resources on this type of prevention. We are focused, 
however, on the early detection of children who have been 
exposed to lead and providing any additional medical services 
they need.

        RESPONSE TO WRITTEN QUESTION OF SENATOR CARPER 
                   FROM RUBEN KING-SHAW, JR.

Q.1. The Administration recently reiterated its commitment to 
screening the blood-lead levels of children under age 6 
enrolled 
in Medicaid. How will you ensure that States comply with this 
requirement?

A.1. CMS is committed to continuing our work with States and 
our Federal partners to ensure that children at highest risk 
are screened for lead poisoning. We continue to reiterate to 
State Medicaid agencies the importance of working with other 
State and local agencies to ensure that children are screened 
and that the data is reported. We will continue to require 
States to report their lead screening data on the CMS-416 Early 
and Periodic Screening, Diagnosis, and Treatment (EPSDT) form 
and monitor States continued progress in this area.
    We also intend to publish the final report prepared by our 
contractor, Abt Associates, that is looking at innovative State 
and local models for the elimination of lead hazards facing 
low-income children, as well as assessing the impact and 
effectiveness of current screening criteria in reaching high-
risk, low-income children. We believe this document will be 
useful to State Medicaid agencies in focusing their resources 
effectively to address this problem.

         RESPONSE TO WRITTEN QUESTIONS OF SENATOR REED 
             FROM RICHARD J. JACKSON, M.D., M.P.H.

Q.1. In your testimony you talk about the CDC's analysis of 
children's blood-lead levels as part of the National Health and 
Nutrition Examination Survey (NHANES) between 1976 and 1980, 
and again between 1991 and 1994. Are there any more recent 
NHANES data available on children's blood-lead levels, and if 
not why?

A.1. There are more data that have not been released yet 
because they are still being analyzed. We hope the data will be 
ready sometime this summer and we will be happy to get it to 
you as soon as it is ready.

Q.2a. Last spring, I, along with several of my colleagues in 
the Senate, wrote to Secretary Thompson to urge the CDC to 
initiate a review of the current blood-lead level (BLL) 
standard of 10 micrograms per deciliter to determine whether 
the national standard needs to be lowered. Last fall, this 
Subcommittee heard about research at the Children's Hospital 
Medical Center in Cincinnati indicating that children exposed 
to lead at levels currently considered ``safe'' scored substantially 
lower on intelligence tests and may be suffering other adverse 
health effects from exposure to lead. What is the status of the 
CDC's review of the current blood-lead level standard and when 
can we expect a report on the outcome of this important review?

A.2a. CDC has requested that the National Advisory Committee on 
Childhood Lead Poisoning Prevention (NACCLPP) study the health 
effects of blood-lead levels less than 10  g/dL (that is, IQ, 
academic performance/achievement, behavior, attentiveness/
reaction time, hearing threshold, growth, renal function, etc.) 
among young children. To support this activity, CDC is funding 
an exhaustive search of the literature on this topic. The 
information will be culled, and the most relevant literature 
will be provided to the ACCLPP ``Less Than 10'' Work Group. 
This Subcommittee of the ACCLPP will review and assess the 
information to determine whether the national standard should 
be lowered. The contract stipulates that a litera-
ture review synopsis will be delivered to the ``Less Than 10'' 
Work Group by May 2003. The work group will consider this 
information and report back to CDC on its findings.

Q.2b. If the blood level standard was changed to five 
micrograms per deciliter, how many more people would be 
estimated to have elevated blood levels?

A.2b. Approximately 3 million based on the 1988 to 1994 NHANES 
data. Again, these data will be updated this summer and we will 
provide a revised estimate when the data are available.

Q.3a. The GAO, in its 1999 report on the lead poisoning 
prevention efforts of Federal health care programs, cited the 
lack of reliable data collection as a significant barrier to 
targeting appropriate services to at risk children. As you 
highlight in your testimony, CDC provides grants to States to 
establish Childhood Blood Lead Surveillance (CBLS) systems. At 
present, how many States have active CBLS systems that are 
collecting screening and elevated blood-lead levels (EBLL) data 
and reporting that data to agencies such as CDC and CMS?

A.3a. All 43 States and 17 local health departments that 
receive funds from CDC for childhood lead poisoning prevention 
programs collect and submit screening and elevated blood-lead 
level data to CDC. Some States, however, do not have laws that 
require that all blood-lead levels be reported. CDC is working 
with those programs to ensure that all blood-lead levels are 
reported in their States. CDC has urged State and local 
childhood lead-poisoning prevention programs to work with their 
State Medicaid offices to link data so we will know what 
percentage of Medicaid enrolled children have been screened for 
lead poisoning.

Q.3b. What kind of oversight or monitoring does CDC conduct to 
ensure that States are maximizing their efforts to develop and 
implement these systems?

A.3b. The CDC lead staff are assigned to work with specific 
States to assess individual childhood lead poisoning prevention 
program's surveillance systems. CDC offers ongoing technical 
assistance to help programs improve their surveillance and use 
of data. CDC is also enhancing its website to highlight model 
programs so that others can learn from the successes. CDC has 
created work groups with State representatives to address different 
surveillance issues. The work groups recommendations will be 
shared with all lead programs. A childhood lead surveillance 
meeting will be held in September 2002 to provide a forum for 
discussion of priority surveillance topics.

Q.4. I understand that the Childhood Lead Poisoning Prevention 
Program's authorization expires this year. As a Member of the 
Senate Health, Education, Labor, and Pensions Committee, I 
would be interested in working with your office to ensure that 
this critical program is reauthorized. What recommendations 
would you offer to help guide the reauthorization of this 
important program?

A.4. [CDC staff discussed with the Reed staff to resolve this 
question . . . authorization was extended by the Children's 
Health Act until 2005.] CDC would be happy to work with you in 
the future to ensure the best reauthorization of the Childhood 
Lead Poisoning Prevention Program.

Q.5a. Primary prevention means making housing lead-safe, 
focusing attention and resources on the ``vector of disease.'' 
However, many health departments are stuck in the rut of 
educating parents about hand washing, nutrition, and wet 
mopping, while science shows that it is not within parents' 
power to protect their children if they live in a highly 
contaminated home. Thus, what is your Agency doing to help deal 
with the vector of disease and help make our housing stock 
lead-safe?

A.5a. CDC is providing supplemental funding specifically 
targeting primary prevention in urban areas of highest need. 
For example, health departments have prenatal clinic and some 
have programs that target new mothers at high-risk for many 
health problems. By identifying these pregnant women and new 
mothers, the health department can go to their homes and 
collect dust samples and offer counseling about lead poisoning. 
If the dust samples are found to have lead, then more intensive 
environmental investigations can be conducted and remediation, 
if appropriate, may occur. This ``primary prevention'' approach 
can prevent young, high-risk children from becoming lead-
poisoned. CDC encourages its programs to apply for HUD grants 
to fund remediation. CDC will require programs in 2003 to begin 
to develop primary prevention programs such as those described 
above.

Q.5b. What more can it do within existing law? Do current laws 
need to be amended to help better deal with primary prevention?

A.5b. Primary prevention, as defined by CDC, is allowed under 
the existing law. However, primary prevention activities will 
be both time and resource intensive, considering these 
activities will be most effective when conducted as a 
complement to the existing lead screening and case management 
activities, which are critical elements in our national 
elimination strategy.

Q.6a. What has CDC done to raise the sights of its grantees 
above screening and case management (reacting to poisoned 
children) and parent education?

A.6a. The CDC has required grantees with the heaviest estimated 
burden to include primary prevention activities in their 
programs. These grantees have implemented the following primary 
prevention activities:

 California has implemented a lead-related construction 
    accredi-
    ation and certification program that provides individuals 
    who 
    are certified to conduct residential lead inspections and 
    risk 
    assessments.
 Ohio's Childhood Lead Poisoning Prevention Program 
    collaborates with the Help Me Grow--Home Nursing Program. 
    Nurses in the Home Nursing Program visit the homes of 
    newborn children and conduct a lead-risk assessment in the 
    home. If risk factors are identified, an environmentalist 
    will follow-up with an 
    environmental inspection.
 New York State is examining the five highest risk 
    counties' Medicaid/Social Service Activities and local 
    agencies housing policies to find ways to revise policies 
    and leverage existing funding to reduce the number of lead-
    contaminated dwellings for low-income families. New York 
    City's program conducts special inspections of one and two 
    family homes when a parent/guardian files a complaint 
    because the landlord has not repaired peeling paint. As a 
    result of these inspections, Commissioner's Orders to Abate 
    can be issued and enforced.
 The Houston CLPPP staff is working on a plan to work 
    with ClearCorps to receive referrals for homes that require 
    hazard reduction.
 In Pennsylvania, the Commonwealth participates in and 
    encourages participation in the ``Lead-Safe Initiative'' 
    which brings together representatives of housing, 
    environmental, social agencies, and others who focus on 
    providing services to children and families incrisis and in 
    adoptive and foster care. In Philadelphia, the city 
    partners with community-based and other Government 
    organizations to visit the homes of expectant and new 
    mothers living in areas at high-risk for lead poisoning. 
    These visits include an assessment of the home including 
    dust-wipe sampling, as well as education and cleaning 
    supplies for the mothers.

    In 2003, all childhood lead poisoning prevention programs 
will need to address primary prevention.

Q.6b. How is CDC helping to keep new children from living in 
the same unsafe housing?

A.6b. CDC has developed a patient tracking and surveillance 
system for childhood lead poisoning. Health departments that 
use this software collect information on where a child lives, 
which allows the health department to identify addresses where 
multiple children/families have been found to have elevated 
blood-lead levels. CDC encourages its grantees to work with 
local housing officials to remediate the homes of children with 
elevated blood-lead levels.

Q.7. In your testimony you talked about the need for lead level 
reporting across all States that would help determine ``hot 
spots.'' You went on to say that this type of data was being 
collected right now. Could you provide additional details about 
this effort including its time line for development and what 
types of information the system will eventually provide?

A.7. CDC is currently receiving blood-lead data for children 
from all the childhood lead poisoning prevention programs. 
CDC's new funding strategy for childhood lead poisoning 
prevention programs will include performance measures. One of 
the new performance measures will be a requirement that States 
require that all blood-lead levels be reported to the State 
health department in a timely manner.

Q.8. While abatement is essential in high-risk properties, in 
which cash flow is insufficient to support maintenance, most 
leaded properties can be made lead-safe through other 
strategies. Research and experience over the past decade has 
demonstrated the importance of visual inspection for peeling 
paint; lead-safe work practices to control, contain, and clean 
up lead dust in painting and remodeling projects; and clearance 
testing to ensure that lead dust hazards are not left behind. 
Do you believe that visual inspection, lead-safe work practices 
and clearance testing offer the potential to expand lead-safety 
to a broad enough scale to make U.S. housing lead-safe?

A.8. Yes, recent studies conducted for the Department of 
Housing and Urban Development (HUD) indicate that lead hazards 
can be controlled with visual inspection, lead-safe work 
practices, and clearance testing can expand lead-safety on a 
broad scale.

Q.9. While consistent data are not widely available, it is 
clear that in the majority of cases lead hazards are not 
corrected even after a child is identified as lead-poisoned. 
The same hazardous house often poisons multiple children as new 
families move in (that is, a Syracuse, New York, newspaper 
identified 47 houses that had poisoned multiple children in 
just 18 months). Even when health departments succeed in 
ordering repairs, in many States there is no oversight, no 
requirement for lead-safe work practices and no clearance 
testing. While no house should poison a child, it is simply 
unconscionable that any house should poison a second, third, 
and fourth child. What do you believe your Agency can do to 
help stop houses from poisoning more that one child?

A.9. It is essential for States to be able to identify lead 
hazards and ensure clean-up. With CDC funding, States have the 
capacity to identify the houses where more than one child has 
been poisoned. Health departments should then use this 
information to work with local housing authorities to assist 
with remediation and enforcement if landlords do not remediate.

Q.10. What does your Agency believe might be appropriate 
statutory changes to make the Federal disclosure law regarding 
lead more meaningful?

A.10. CDC believes that increasing community awareness 
particularly among renters and homeowners about the hazards of 
lead and how lead poisoning can be prevented is important.

Q.11. Many advocates and some health departments are convinced 
that ending childhood lead poisoning will require moving beyond 
screening children's blood-lead levels to actually screening 
high-risk housing to identify hazards before a child's health 
is harmed. What does your Agency think about this strategy? 
What about the idea of developing registries of hazardous 
properties?

A.11. CDC completely supports the strategy to move toward 
screening high-risk housing to identify hazards before a 
child's health is harmed. Nevertheless, CDC believes that an 
important component of the lead elimination strategy is 
screening for children with elevated blood-lead levels and 
offering medical and environmental interventions when 
appropriate. Registries of homes with hazards, as well as lead-
safe homes should be a part of a comprehensive primary 
prevention strategy.

Q.12. Does your Agency believe that lead-based paint and dust 
hazards in housing are the overwhelming cause of childhood lead 
poisoning in the United States? If not, what other causes 
should Congress be looking at?

A.12. Lead-based house paint contaminates dust and soil and 
these sources are the most common high dose source of lead 
exposure for young children in this Nation. While there are 
other sources of lead exposure for young children, such as 
certain folk remedies, cultural cosmetics, and water, CDC 
believes that addressing leaded house paint will make a huge 
impact on protecting our Nation's children from the life-long 
affects on their health. Elimination will require identifying 
all potential sources of exposure for a child and making the 
environment lead-safe.

Q.13a. As a result of our hearing last November on lead 
poisoning, it was clear that primary prevention is an extremely 
important part of eliminating childhood lead poisoning. First 
of all, does your Agency support the goal of stopping children 
from being poisoned in the first place?

A.13a. CDC has been emphasizing the importance of preventing 
children from ever becoming lead-poisoned, since the 
publication of its 1991 document, Preventing Lead Poisoning in 
Young Children. CDC support of primary prevention is stressed 
in its 2002 document, Managing Elevated Blood Lead Levels Among 
Young Children.

Q.13b. If so, how is your Agency planning to achieve this goal?

A.13b. The CDC has already required grantees with the heaviest 
estimated burden, California, Illinois, Ohio, Pennsylvania, and 
Texas, to address primary prevention, but in 2003 all programs 
will be required to address primary prevention. Funding will 
help childhood lead poisoning prevention programs introduce 
more primary prevention activities. CDC will facilitate 
networking among programs, so grantees can learn from each 
others experiences. CDC will enhance its website to provide 
more information on existing and past primary prevention 
activities. As we increase primary prevention activities, we 
must remember that screening and case management must remain 
strong and effective. Primary prevention, screening and case 
management are critical to achieve our 2010 elimination goal.
