[Congressional Record Volume 145, Number 148 (Wednesday, October 27, 1999)]
[Senate]
[Pages S13243-S13248]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




           NATIONAL CHILDHOOD LEAD POISONING PREVENTION WEEK

  Mr. REED. Mr. President, I rise today to speak with respect to 
National Childhood Lead Poisoning Prevention Week. Because of the 
efforts of my colleagues, Senator Collins, Senator Torricelli, and 
myself, this Senate passed a bipartisan resolution a last week to 
commemorate, during the week of October 24 to 30, National Childhood 
Lead Poisoning Prevention Week.
  I think it is appropriate to recognize this problem that is taking 
place throughout this country and also recognize what we are trying to 
do to alleviate this great problem.
  As a preliminary point, let me commend my colleague, Senator Collins, 
for her great efforts in this regard. She has been a true leader in 
this issue. She has been someone who has fought the good fight with 
respect to this problem. She has participated legislatively. I was very 
pleased and honored a few weeks ago to have her join me in Providence, 
RI, for a hearing on this issue. I look forward to joining her in a few 
weeks in Maine so we can examine the experience in her home State.
  I also want to commend my colleague, Senator Torricelli, who also is 
very active as a leader in this effort. Indeed, Senator Torricelli and 
I have introduced legislation, the Children's Lead SAFE Act of 1999, 
which is critically important to the future of our children in the 
United States.
  This importance has been underscored and highlighted by two recent 
reports--one earlier this year in January of 1999 by the General 
Accounting Office, and another report that has been released recently 
under the auspices of the Alliance To End Childhood Lead Poisoning and 
the National Center for Lead-Safe Housing.
  Both of these reports underscore the need for additional efforts to 
eliminate childhood exposure to lead and also to provide additional 
support for screening and treatment of children who are exposed to 
environmental lead.
  Regrettably, there are too many children in this country who are 
exposed to lead, typically through old lead paint that may be in their 
home. It is particularly critical and crucial to children who are at a 
very young age, under the age of 6, because their body is much more 
likely to absorb this environmental hazard, and also because those are 
exactly the times in which brain nervous systems are developing, where 
cognitive skills are being developed. We know lead is the most 
pernicious enemy of cognitive development in children.
  In the United States, too many children are poisoned through this 
constant exposure to low-levels of lead in their atmosphere. This 
exposure leads to reduced IQ, problems with attention span, 
hyperactivity, impaired growth, reading and learning disabilities, 
hearing loss, and a range of other effects.
  Lead poisoning is entirely avoidable, if we have the knowledge and 
the resources and the effort to prevent young children from being 
exposed to lead.
  In January of this year, as I indicated, the General Accounting 
Office highlighted the problems in the Federal health care system with 
respect to lead screening and followup services for children.
  We have policies that require all Medicaid children to be screened 
for lead. Sadly, we have not achieved that level of 100 percent 
screening. We want to reach that goal. Then after screening all of the 
children in the United States who may be vulnerable to lead poisoning, 
we want to ensure these children have access to followup care. 
Identifying poisoned children is only the first step and is only 
effective when coupled with proper follow-up care.
  Most recently, we received information about that follow-up care from 
a report, the title of which is: ``Another Link in the Chain: State 
Policies and Practices for Case Management and Environmental 
Investigation for Lead-Poisoned Children.'' As I indicated, this report 
was sponsored by the Alliance To End Childhood Lead Poisoning and the 
National Center for Lead-Safe Housing.
  This report presents a State-by-State analysis of data which 
suggests, first, there have been some innovative steps taken by the 
States, but unfortunately there are disappointing gaps in the screening 
and treatment of children who are exposed to lead throughout the United 
States.
  There is also a great range among the States in their response to 
this problem of childhood lead poisoning. In my own State of Rhode 
Island, we have taken some very aggressive steps. Last week, we 
dedicated a lead center in Providence, RI, which provides comprehensive 
services for lead-poisoned children, including parent education, 
medical followup for children who have been exposed, and transitional 
housing. Many times the source of the pollution is in the home of these 
children, and because of their low income, there is no place for them 
to go unless there is this transitional housing. This is an innovative 
step forward. I am very pleased and proud to say it has taken place in 
my home State.
  If you look across the Nation, you find much less progress. Nearly 
half of the States have no standards for case management and, thus, the 
quality of care lead poisoned children receive is often not consistent 
with public health recommendations. There is no real way to ensure 
these children are getting the type of care they need because there are 
no case management policies. Only 35 States have implemented policies 
that address when an environmental investigation should be performed to 
determine the source of a child's lead poisoning. There are many States 
where there is no way to determine where the source of the pollution is 
coming from that is harming the child.
  In addition, the report points out that despite the availability of 
Medicaid reimbursement for environmental investigation and case 
management, more than half the States have not taken advantage of this 
Medicaid reimbursement. In addition, despite the emphasis we have in 
Medicaid on screening children, only one-third of the States could 
report on how many of their lead poisoned children were enrolled in 
Medicaid, suggesting that screening data are not being coordinated, and 
there really is not comprehensive, coherent screening policy in all too 
many States.
  Senator Torricelli and I have proposed legislation that would address 
these deficiencies. The legislation will improve the management 
information systems so States know how many children are screened and 
how many children have been exposed. We also encourage them to 
integrate all the different agencies and institutions and programs that 
serve children so we can

[[Page S13244]]

have a comprehensive approach. This would include involving the WIC 
program in the screening, early Head Start, maternal and child health 
care block grant programs, so we have a comprehensive approach to 
identifying, treating, following up and educating with respect to lead 
exposure.
  We are committed to doing that. We are committed to ensuring that 
every child in this country, particularly those children who are 
beneficiaries of the Medicaid system, have this kind of screening and 
followup.
  Unfortunately, we have found too many States that are not following 
through on their obligations. Of the 38 States that have enrolled 
Medicaid children to managed care plans, only 24 reported that their 
State's contract with the managed care organization contained any 
language about lead screening or treatment services. So, many States 
are leaving it up to the managed care company or merely leaving it up 
to chance whether or not there are good protocols to follow up on lead 
exposure.
  In addition to that, more than 40 percent of States reported that no 
funding is available to help pay for even a portion of the hazard 
control necessary to make a home lead safe for a lead-poisoned child. 
There are not the resources to help these families cope with the 
reality of homes that are literally poisoning and harming their 
children. That is one reason why I joined my colleague, Senator 
Torricelli, to address this problem with respect to the Children's Lead 
SAFE Act of 1999. We would like to see clear and consistent standards 
for screening and treatment to ensure that no child falls through the 
cracks. We would to help communities, parents and physicians take 
advantage of every opportunity they have to detect and treat lead 
poisoning.

  This bill is just one element in a comprehensive, coherent approach 
to eliminate this preventable disease that afflicts too many children 
in this country today.
  I was pleased that during the appropriations process, the Senate 
supported the President's request for full funding of the lead hazard 
control grants program--indeed, particularly pleased when the conferees 
agreed with the Senate and maintained this funding. It is absolutely 
critical. We will continue to press forward in terms of screening and 
treatment, in terms of reducing lead hazards in the homes of children, 
and in terms of education, so there is no place in this country that 
fails to recognize the gravity of this situation where children are 
poisoned by exposure to lead.
  Indeed, that is why we are here today. This week is National 
Childhood Lead Poisoning Prevention Week. We hope by reserving 1 week a 
year to emphasize the challenges we face, to emphasize the steps which 
must be taken in the future, we can galvanize additional support so 
there is no child in this country who is poisoned by lead, whose 
development--physical, mental, social development--is harmed by such 
exposure.
  At the heart of this effort is the work of many people, but, once 
again, I thank my colleague and friend, Senator Susan Collins, who has 
taken it upon herself to charge forward to make this hope of a lead-
safe environment for all our children a reality. I am pleased to be 
with her sponsoring this resolution, sponsoring this week of 
commemoration and also, in the days ahead, working to ensure that all 
the children are as free as we can make them from the harm and the 
danger of lead exposure.
  I ask unanimous consent that the Presidential message recognizing 
National Childhood Lead Poisoning Prevention Week and the executive 
summary of ``Another Link in the Chain,'' be printed in the Record, 
following my statement.
  There being no objection, the materials were ordered to be printed in 
the Record, as follows:

                                              The White House,

                                     Washington, October 20, 1999.
       Warm greetings to everyone observing National Childhood 
     Lead Poisoning Prevention Week.
       As America's children begin their exciting journey into the 
     21st century, one of the greatest gifts we can give them is a 
     healthy start. Sadly, however, many children face needless 
     obstacles to healthy development in their own homes. Among 
     the most devastating of these obstacles is lead poisoning. 
     Today nearly 5 percent of children between the ages of 1 and 
     5 suffer from this condition. While any child can be 
     susceptible to lead poisoning and its effects, low-income 
     children are at a significantly higher risk, since most 
     children are poisoned by lead-based paint and lead-
     contaminated dust and soil that are found in older, 
     dilapidated housing. For African-American children living in 
     these conditions, the rate of those who suffer from lead 
     poisoning is a staggering 22 percent.
       The effects of lead poisoning can be serious and 
     irrevocable. Even low levels of exposure to lead can hinder 
     children's ability to learn and thrive, reducing their IQ and 
     attention span and contributing to learning disabilities, 
     hearing loss, impaired growth, and many other developmental 
     difficulties. My Administration, through the Department of 
     Housing and Urban Development and the Environmental 
     Protection Agency, has taken important steps to eliminate the 
     threat of lead poisoning. We have provided funding for such 
     efforts as removing lead-based paint from housing built prior 
     to 1978, when such paint was outlawed. We have also promoted 
     increased blood testing of young children to determine the 
     levels of lead in their blood.
       However, when our children's well-being is at stake, we 
     must do more. I commend the concerned citizens and 
     organizations participating in this year's observance for 
     raising awareness of the dangers of lead poisoning and for 
     teaching families and communities how to prevent it. I urge 
     all Americans to take this occasion to learn more about lead 
     poisoning and to take part in local, state, and national 
     efforts to create a healthier environment for our children.
       Best wishes for a successful week.
     Bill Clinton.
                                  ____


                      Chapter 1--Executive Summary

       The first line of defense in protecting children from lead 
     poisoning is primary prevention, which means controlling lead 
     hazards before children are ever exposed to lead. However, 
     the broad distribution of lead in the U.S. housing stock has 
     made achieving primary prevention for all children an elusive 
     goal. As a result, secondary prevention strategies continue 
     to play a vital role in protecting children from lead 
     poisoning. Secondary prevention entails identifying the lead-
     poisoned child, providing medical care and case management, 
     identifying the source of the child's lead exposure 
     (environmental investigation), and then ensuring that any 
     lead hazards identified are controlled to prevent the child's 
     further exposure to lead.
       Over the past few years, there has been considerable public 
     attention to and controversy surrounding policies for 
     screening young children for lead poisoning. There has also 
     been considerable discussion about primary prevention and 
     housing-based approaches to primary prevention, as a 
     consequence of enactment of Title X and federal funding for 
     the HUD Lead Hazard Control Grants program. In contrast, 
     there has been little discussion of what actually happens 
     once a lead-poisoned child is identified. The Alliance To End 
     Childhood Lead Poisoning and the National Center for Lead-
     Safe Housing agreed that it was time to reexamine the 
     response to lead-poisoned children nationwide. We decided 
     that characterizing the case management and environmental 
     investigation services now being provided in each state would 
     be a useful first step. We hope this report's documentation 
     of state policies will help sharpen discussion and decision-
     making at many levels. This report is timely for at least 
     four reasons.
       First, this report provides the information needed to 
     ensure that case management and environmental investigation 
     systems are ``in good working order'' to handle the increased 
     caseloads that can be expected from expanded lead screening 
     of high-risk children. Recent reports from the General 
     Accounting Office (GAO) have focused the spotlight on the 
     failure of federal health programs to screen high-risk 
     children for lead poisoning. GAO documented that just 19% of 
     Medicaid-enrolled children aged 1 through 5 are being 
     screened as required by law, and that the majority of 
     children needing case management and environmental 
     investigation are enrolled in Medicaid. As a consequence, 
     considerable attention is being paid now to improving lead 
     screening rates among Medicaid children. In addition, many 
     states are developing CDC-recommended lead screening plans to 
     identify and target the highest-risk children for lead 
     screening.
       Second, this report raises a number of policy and program 
     issues that should be considered as states seek to ensure 
     that lead-poisoned children enrolled in Medicaid managed care 
     plans are provided with appropriate follow-up care. Many 
     states are still developing or fine-tuning their mechanisms 
     for overseeing and coordinating care with Medicaid managed 
     care plans, as well as state Children's Health Insurance 
     Programs.
       Third, this report can help to inform a number of pending 
     policy decisions. The Health Care financing Administration 
     has been receiving criticism from many quarters for its 
     policy prohibiting Medicaid reimbursement for analysis of the 
     environmental samples needed for an adequate environmental 
     investigation to identify the lead hazards in a poisoned 
     child's home. In addition, the Centers for Disease Control 
     and Prevention's Advisory Committee on Childhood Lead 
     Poisoning Prevention is currently reviewing the evidence base 
     for case management services. Finally, U.S. Senators Robert 
     Torricelli (D-NJ) and Jack Reed (D-RI) and U.S. 
     Representative Robert Menendez (D-NJ) are introducing federal 
     legislation to address these issues in Congress.

[[Page S13245]]

       Fourth, the sharp decline in the number of children with 
     elevated blood lead levels documented by NHANES III, Phase 2 
     offers opportunities never before available for using 
     screening and follow-up measures to advance prevention. For 
     the first time, the caseload of lead-poisoned children in 
     jurisdictions historically overwhelmed by the number lead-
     poisoned children has become ``manageable.'' We have a 
     responsibility to respond promptly and humanely to children 
     with elevated blood lead levels as well as the opportunity to 
     use these interventions to advance prevention. Childhood lead 
     poisoning is entirely preventable. But achieving this goal 
     requires us to sharpen our tools and redouble prevention 
     efforts, rather than being complacent or uncritically flowing 
     ``established procedures'' by rote.


                          scope of the survey

       The scope of this survey and report is limited to 
     describing and evaluating the quality of self-reported state 
     policies and practices for environmental investigation and 
     case management. This report therefore could not assess state 
     primary prevention initiatives, lead screening policies and 
     performance, or even medical care provided to lead-poisoned 
     children. The most effective state programs are those that 
     succeed at primary prevention. Once a child is exposed to 
     lead, the overall effectiveness of the response must be 
     judged by performance in all three areas of secondary 
     prevention--and a single weak link in the chain of secondary 
     prevention activities can undermine the effectiveness of the 
     entire response. Having exemplary environmental investigation 
     and case management services is useless if the state fails to 
     screen children at risk for lead poisoning to identify those 
     with elevated blood lead levels. Similarly, providing good 
     environmental investigation and case management services is 
     pointless if these activities do not trigger action to 
     control identified lead hazards.
       It is also important to be clear about what is meant by 
     each key term. ``Environmental investigation'' means the 
     examination of a child's living environment, usually the 
     home, to determine the source or sources of lead exposure for 
     a child with an elevated blood lead level. For the purposes 
     of this report, ``case management'' means coordination, 
     provision, and oversight of the services to the family 
     necessary to ensure that lead-poisoned children achieve 
     reductions in blood lead levels. In addition, case management 
     includes coordination, but not provision and oversight, of 
     the clinical or environmental care.


                    survey methodology and responses

       To gather the information about current policies and 
     practices for case management and environmental 
     investigation, an initial survey and a supplementary survey 
     were sent to directors of state lead poisoning prevention 
     programs. In states where these programs do not exist, we 
     identified knowledgeable respondents by contacting 
     surveillance grantees of the Centers for Disease Control and 
     Prevention (CDC) or other program staff responsible for lead 
     services (often a division of the state health department). 
     Ultimately, we received responses from all 50 states and the 
     District of Columbia. We also received responses from 15 
     local lead programs, which allowed us to better characterize 
     several important dimensions of current practice of state 
     programs.


        key findings and recommendations on initiating services

     State blood lead reporting systems
       Central reporting of elevated blood lead levels is critical 
     to ensuring timely follow-up care for lead-poisoned children. 
     Although nearly all (47) states have a reporting system for 
     blood lead levels, the utility of the systems for timely 
     referral of children needing follow-up services varies 
     considerably. In addition, the lack of uniform national 
     recommendations for reporting blood lead levels has created a 
     burden on private laboratories and others that must report 
     this information to many different states in a variety of 
     formats, and has made it difficult to assess and compare 
     blood lead data across states.
       CDC should establish national standards for blood lead 
     reporting to ensure standardization of blood lead data and 
     enable timely follow-up for lead-poisoned children.
       States with blood lead reporting systems should evaluate 
     the effectiveness of their systems in triggering prompt 
     identification and follow-up of lead-poisoned children and 
     address any identified deficiencies.
       States without a central reporting system for blood lead 
     levels should establish one as soon as possible.
     Blood lead levels at which services are provided
       CDC's 1997 guidance recommends that both case management 
     and environmental investigation be provided at blood lead 
     levels of 20 g/dL or persistent levels of 15-19 
     g/dL. Encouragingly, most states are providing 
     services to children at or even below the blood lead 
     thresholds recommended by CDC. For environmental 
     investigation, 20 states perform environmental investigation 
     only at blood lead levels at or above 20 g/dL (not 
     persistent levels above 15 g/dL) and 2 states use a 
     trigger of 25 g/dL. Since environmental 
     investigation permits the identification and subsequent 
     control of lead hazards, early hazard identification by 
     providing environmental investigation at lower blood lead 
     levels is a positive preventive measure.
       Some states are able to vary the scope of case management 
     services provided by blood lead level, providing less 
     intensive services at lower blood lead levels in order to 
     intervene before blood lead levels rise. Thus, it is not 
     surprising that many states report offering case management 
     at lower blood lead levels than recommended by CDC. Six 
     states offer case management at precisely the level 
     recommended by CDC, and 28 states offer the service at lower 
     levels (single levels above 15 g/dL or 10 
     g/dL). Fourteen states provide case management only 
     at blood lead levels of 20 g/dL, but not persistent 
     levels between 15 and 19 g/dL as recommended by CDC.
       At a minimum, states should provide case management and 
     environmental investigation to children at the levels 
     recommended by CDC, and, resources permitting, preventive 
     services and environmental investigation to as many children 
     as possible with blood lead elevations at or above 10 
     g/dL.


   key findings and recommendations on setting standards for services

     Case management standards
       The lack of national standards for case management of lead-
     poisoned children has created variation in approach across 
     the country, and made achieving reimbursement from Medicaid 
     and other insurers more difficult. At present, only 29 state 
     programs indicated they had written standards for case 
     management. However, a consensus document Case Management for 
     Childhood Lead Poisoning, developed by the National Center 
     for Lead-Safe Housing, describing professional standards for 
     case management for lead-poisoned children already serves as 
     a guide for some state and local programs. Other 
     complementary documents exist or are under development.
       Any case management protocol or standard must include 
     certain elements to ensure quality care. Our survey found 
     that states performed well in some areas, but needed 
     improvement in others. For example, although most states (43) 
     provide home visits as part of case management, many programs 
     make only a single home visit, which is unlikely to be 
     sufficient for ensuring that steps are taken to improve the 
     health status of the child. In addition, almost one-third 
     (29%) of programs fail to inquire about a lead-poisoned 
     child's WIC status, an important oversight given the 
     importance of good nutrition for lead-poisoned children. 
     Because they are an essential part of the solution, families 
     should be systematically involved in all aspects of the case 
     management process. Yet, our survey found that more than one-
     third of state programs (37%) fail to include families in the 
     planning process and only one state program indicated that it 
     routinely refers families to parent support groups in the 
     community. The indefinite continuation of cases is also a 
     sign of a weak case management, yet 14 states reported that 
     they had no criteria for when to close a case.
       Case management standards must also describe the specific 
     interventions to improve the health status of the child that 
     should be provided by case managers. Nearly all states 
     provide some type of educational intervention, including 
     education focused on lead and lead exposure risks, lead-
     specific cleaning practices, and nutritional counseling. Two-
     thirds of state programs (67%) provide assistance with 
     referrals to other necessary services and 80% provide follow-
     up of identified problems. Six state programs indicate that 
     they now refer young children routinely to Early 
     Intervention programs for identification and treatment of 
     possible developmental problems. Surprisingly, 10 states 
     provide specialized cleaning services to reduce immediate 
     lead dust hazards in homes as part of their case 
     management interventions. However, due to funding 
     considerations, most of these states are not able to make 
     cleaning available except in homes in designated target 
     areas and under special circumstances.
       All states should have in place a protocol that identifies 
     minimum standards for initiation, performance, and tracking 
     of case management services for lead-poisoned children, 
     including standards for data collection and outcome 
     measurements and for professional staffing and oversight.
       CDC or its Advisory Committee on Lead Poisoning Prevention 
     should endorse a set of national standards for case 
     management for lead-poisoned children, beginning with a 
     definition of the term case management. The consensus 
     standards developed by the National Center for Lead-Safe 
     Housing (Case Management for Childhood Lead Poisoning) offer 
     a thorough, current, and complete set of expert standards for 
     quick review and endorsement.
       Once national standards are in place, state protocols 
     should be reviewed for consistency. In the interim, states 
     should utilize written protocols specifying the services to 
     be provided along with performance standards and record-
     keeping criteria.
       Case management standards should include a minimum of two 
     case management visits to the home of a lead-poisoned child.
       State case management protocols should include standards 
     for assessment, specifically including assessment of WIC 
     status.
       State programs should evaluate the extent to which families 
     are being involved in case management and make necessary 
     program modifications to ensure that families are fully 
     involved in planning, implementation, and evaluation efforts.
       States should examine their referral practices to ensure 
     that parents of lead-poisoned children are routinely referred 
     to available resources, including community-based parent 
     support groups, where they exist, in order to connect 
     families with another source of support and assistance.

[[Page S13246]]

       All states should have case closure criteria that encompass 
     reduction in a child's blood lead level and control of 
     environmental lead hazards and procedures for administrative 
     closure when needed.
       States that routinely follow children until 6 years of age 
     should evaluate whether such a lengthy follow-up benefits the 
     child and family.
       Case management standards should specify recommended 
     interventions, including: basic educational interventions; 
     referrals to Early Intervention services for developmental 
     assessment, referral services for WIC, housing (emergency and 
     long-term Solutions), health care, and transportation, as 
     needed; follow-up of identified problems as needed; and, 
     follow-up to ensure that families receive needed services.
     Environmental investigation standards
       State programs vary widely as to what activities constitute 
     an environmental investigation to determine the source of 
     lead exposure. Only 35 states have written protocols for 
     environmental investigation. Where written protocols do 
     exist, the scope of services and the kinds of data 
     collected vary extensively. For example, some programs 
     rely almost exclusively on XRF analysis to test the lead 
     content of paint, and interpret a positive reading for the 
     presence of lead-based paint as source identification. 
     Other programs focus on current pathways of exposure by 
     taking dust wipe and paint chip samples, assessing paint 
     condition, and in some cases evaluating exposures from 
     bare soil and drinking water. And, still other programs 
     operate on a case-by-case basis.
       Just 35 states had minimum requirements in place for those 
     who perform environmental investigations for lead-poisoned 
     children; most frequently they required state-certified risk 
     assessors or lead inspectors. Training in the certified 
     disciplines of risk assessor and lead inspector provides a 
     core foundation of knowledge as well as credentials that may 
     be important in any legal proceedings. At the same time, 
     additional training beyond these certified disciplines is 
     needed, because the scope of the environmental investigation 
     of a lead-poisoned child is much more comprehensive than a 
     standard residential lead inspection, and somewhat broader 
     than a risk assessment.
       The responses to our survey do not make it possible to 
     determine the extent to which states are performing (or 
     requiring to be performed) clearance testing after work has 
     done to respond to lead hazards identified in the home of a 
     lead-poisoned child. Follow-up visits are essential to ensure 
     that corrective measures were taken and lead safety 
     precautions followed. Because lead-contaminated dust can be 
     invisible to the naked eye, clearance dust tests are critical 
     to ensure the effectiveness and safety of the corrective 
     measures in the vast majority of situations. Post-activity 
     dust tests should be taken after completion of any paint 
     repair or other projects that could generate lead-dust 
     contamination.
       Many program staff expressed frustration that environmental 
     investigations frequently do not result in any corrective 
     action. The ultimate measure of the success of an 
     environmental investigation is the action that results to 
     control lead hazards to reduce the child's continued lead 
     exposure. At the extreme, conducting a full environmental 
     investigation is irrelevant if no measures to reduce lead 
     exposure occur as a consequence.
       States should have a written protocol identifying the 
     components of an environmental investigation for a lead-
     poisoned child. Appropriate flexibility and customization 
     based on specific case factors and local sources are 
     legitimate and important elements.
       The protocol for environmental investigation should include 
     routine collection of data on important pathways of exposure 
     (particularly interior dust lead) and documentation of poor 
     paint condition. The XRF analyzer should never be relied upon 
     as the only tool for environmental investigation. Chapter 16 
     of HUD's Guidelines for the Evaluation and Control of Lead-
     Based Paint Hazards in Housing provides the most 
     comprehensive and current guidance for environmental 
     investigations.
       State programs should begin using the more protective dust 
     lead standards being proposed by EPA and HUD: no higher than 
     50 g/square foot for floors and 250 g/
     square foot for window sills.
       Environmental investigations need to generate 
     ``actionable'' data to ensure that all lead 
     hazards identified are controlled--the ultimate measure of 
     effectiveness. In most states, improved systems are needed 
     to document and track corrective actions to control lead 
     hazards to help ensure that environmental investigations 
     actually result in health benefits to children.
       Health department program staff performing an environmental 
     investigation for a lead-poisoned child should be trained and 
     certified as lead professionals. This will serve to increase 
     professionalism in the field as well as give the results of 
     the investigation greater standing if challenged in court.
       Individuals conducting environmental investigations need 
     additional training to assess sources of lead exposure beyond 
     the scope of the traditional EPA/HUD risk assessment.
       When state or local programs or managed care organizations 
     contract environmental investigations out to certified lead 
     evaluators, it is important that they be charged with 
     conducting a comprehensive evaluation of potential exposure 
     sources as described in Chapter 16 of HUD's Guidelines for 
     the Evaluation and Control of Lead-Based Paint Hazards in 
     Housing.
       State programs need to make clearance dust tests a routine 
     check to confirm that lead dust hazards are not left behind 
     after corrective measures are taken in the home of a lead-
     poisoned child.
     Lead hazard control: Legal authority and resources
       Although this survey was not able to quantify the extent to 
     which state and local programs succeed in controlling hazards 
     identified in home of a lead-poisoned child, many programs 
     indicated that this is a major problem. Twenty-eight states, 
     more than 54%, do not have legal authority to order 
     remediation of homes with identified lead hazards. More than 
     40% of all states (22 state programs) indicate that no 
     funding is available in their state to help property owners 
     pay for even a portion of the necessary lead hazard control. 
     No state reported sufficient funds for lead hazard control. 
     The lack of legal authority to order remediation coupled with 
     the lack of resources to fund abatement and lead hazard 
     control is a major stumbling block for lead poisoning 
     prevention and treatment progress nationally.
       States should consider the model legislative language 
     reflecting the principles and recommended lead-safety 
     standards of the National Task Force of Lead-Based Paint 
     Hazard Reduction and Financing developed by the National 
     Conference of State Legislatures.


         key findings and recommendations on financing services

       For both case management and environmental investigation, 
     adequate funding for services is a central challenge to 
     providing timely and quality services. Most programs have 
     patched together funding from federal, state, and local 
     sources as best they can. For case management, 23 states 
     reported relying primarily on federal funds, 12 states rely 
     primarily on state funds, and 4 states on Medicaid. Six 
     states reported a combination of sources. Even in states with 
     Medicaid reimbursement, Medicaid provides only part of the 
     support for case management. For environmental investigation, 
     CDC grant funds are the most common source of funds for 
     environmental investigation, with 22 states reporting 
     reliance on this funding source; some use CDC funds 
     exclusively. Medicaid reimbursement is the next most common 
     source of funding for environmental investigation, with 20 
     states receiving at least some reimbursement for services 
     provided for Medicaid-enrolled children. State funds 
     provide support in 17 states and local or county funds in 
     15 states. Other sources fill in the gaps.
       However, it appears that financing is not the strongest 
     area of state case management and environmental investigation 
     programs. Many state program staffs are not aware of how 
     their programs actually receive funds for case management and 
     environmental investigation services, and others seemed to be 
     confused about the concept of ``reimbursement'' for services. 
     At least 6 states provided different answers to the GAO than 
     they provided to us on the question of state Medicaid policy 
     for reimbursement of environmental investigations. GAO 
     surveyed EPSDT agencies while we surveyed program staff 
     responsible for lead-related services, but both should be 
     expected to be able to answer this question accurately.
       Twenty states currently seek and receive Medicaid 
     reimbursement for case management, and 22 states report 
     Medicaid reimbursement for environmental investigation, 
     (although apparently slightly fewer are actually collecting 
     Medicaid dollars at this time). States using state (or local) 
     funds for environmental investigation or case management 
     without receiving Medicaid reimbursement are effectively 
     forgoing the federal Medicaid match for state spending. By 
     all rights, Medicaid should pay the costs of these medically 
     necessary treatment services for enrolled children. In 
     addition, by securing Medicaid reimbursement, states may be 
     able to shift the state's share of costs to the Medicaid 
     budget, rather than using the limited funds designated for 
     lead poisoning prevention or other public health functions. 
     Similarly, states that use CDC lead poisoning prevention 
     grant funds for environmental investigation without securing 
     Medicaid reimbursement should consider the opportunity costs. 
     Since CDC grant funds are finite and scarce, the decision not 
     to seek Medicaid reimbursement means forgoing other possible 
     uses, such as initiatives targeted to primary prevention.
       The amounts reimbursed by Medicaid for both services vary 
     dramatically from state to state, ranging from $38 to $490 
     for environmental investigation and from $25 for one 
     educational visit to a maximum of $1,610 for 8 months of 
     follow-up for case management. Although the set of services 
     provided varies to some extent state-by-state, the actual 
     cost of providing the services is unlikely to vary so widely. 
     Ideally, reimbursement should reflect the actual costs of 
     service delivery. State and local programs cannot 
     successfully bill Medicaid or managed care for services 
     provided unless they can document the actual cost of 
     providing those services.
       States following HUD Guidance for investigating the home of 
     a lead-poisoned child are likely to need to conduct a number 
     of specific laboratory tests, possibly including interior 
     dust wipes, paint chips, soil, and drinking water. Yet a 
     vital source of funding for environmental investigation has 
     recently been restricted. In September 1998, HCFA

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     erected a barrier to quality care when it ``clarified'' its 
     policy on reimbursement for environmental investigation in 
     its update to the State Medicaid Manual. HCFA's written 
     policy now inappropriately prohibits reimbursement for the 
     environmental sampling and analysis (such as measuring lead 
     in dust, soil, and water) that is needed to investigate the 
     source of lead exposure in a poisoned child's home--and makes 
     it impossible to achieve the essential purpose of 
     environmental investigation. In effect, the new language 
     limits coverage only to XRF analysis to determine the lead 
     content of paint, which usually does not confirm the 
     immediate exposure hazard or reveal what control action is 
     needed to reduce exposure.
       Several states reported arbitrary limits on State Medicaid 
     reimbursement for environmental investigation services, such 
     as limiting payment to one investigation per child per 
     lifetime. It appears that such limits on environmental 
     investigation are illegal, since the federal EPSDT statute 
     entitles Medicaid children to all services medically 
     necessary to respond to a condition identified during an 
     EPSDT screen.
       Only one-third of states could report how many or what 
     percentage of their cases were even enrolled in Medicaid. 
     States must be able to document the number of Medicaid-
     enrolled children receiving services in order to receive or 
     make informed decisions about reimbursement.
       Thirty-eight states reported the enrollment of at least 
     some Medicaid children into managed care plans, but only 24 
     of these reported that their state's contract(s) with managed 
     care organizations (MCOs) contained any language about lead 
     screening or treatment services. Most reported that the 
     language dealt only with lead screening or generic EPSDT 
     screening requirements, missing an opportunity to describe 
     clear duties for health care providers for lead screening and 
     follow-up care.
       State Medicaid agencies that have not yet established 
     mechanisms for Medicaid reimbursement for case management and 
     environmental investigation should do so immediately.
       Health departments providing case management and 
     environmental investigation should contact the Medicaid 
     agency to ensure that reimbursement is available to public 
     sector service providers, customized for the specific 
     situation.
       CDC should require its CLPP grantees to pursue Medicaid 
     reimbursement of case management and environmental 
     investigation as a condition of funding.
       HCFA should revise its guidance to permit Medicaid 
     reimbursement for the costs of the laboratory samples 
     necessary to determine the source of lead exposure in the 
     home of a lead-poisoned child.
       Medicaid should fund emergency services to reduce lead 
     hazards for children with EBL, including lead dust removal 
     and interim measures to immediately reduce hazards in the 
     child's home. If the child's home can not be made safe, 
     Medicaid should reimburse the cost of emergency relocation.
       State programs should determine and document the actual 
     costs of providing case management and environmental 
     investigation services.
       State lead programs should negotiate adequate reimbursement 
     rates with the State Medicaid agency, based on documentation 
     of the costs of providing services.
       Based on current costs of service delivery, state and local 
     programs should ensure that their budgets and funding 
     requests seek the resources necessary to adequately manage 
     their caseloads.
       States should consider billing private insurance providers 
     for services provided to children enrolled in such plans.
       HCFA should disallow, and states should discontinue the use 
     of, arbitrary limits on State Medicaid reimbursement for 
     environmental investigation services unless they are shown 
     to have a medical basis.
       State programs should establish the administrative means 
     necessary to track the insurance status (especially Medicaid 
     enrollment) of lead-poisoned children receiving case 
     management and environmental investigation services.
       CDC should require its CLPP and Surveillance grantees to 
     pursue collection of data on the insurance status (especially 
     Medicaid enrollment) of the children receiving case 
     management and environmental investigation services.
       State Medicaid contracts with MCOs should contain clear 
     language describing the specific duties of the MCOs, making 
     clear whether they are expected to deliver services, make 
     referrals, or provide reimbursement to other agencies for 
     services provided. States should address lead screening, 
     diagnosis, treatment, and follow-up services explicitly, 
     rather than relying on general language referencing EPSDT. 
     States should familiarize themselves with and utilize the 
     lead purchasing specifications for Medicaid management care 
     contracts that have been developed by the Center for Health 
     Policy and Research at the George Washington University 
     (available at ``www.gwumc.edu/chpr''). Where such language 
     has already been incorporated into contracts, it should be 
     enforced.
       Where case management and environmental investigation are 
     provided by public sector providers and Medicaid children are 
     enrolled in capitated managed care plans, states should 
     consider financing case management and environmental 
     investigation through a ``carve-out'' to ensure that 
     providers are reimbursed for their costs of providing 
     services.


  key findings and recommendations on tracking and evaluating services

       Very few programs are tracking outcomes of children 
     identified as lead poisoned. Most states count the number of 
     home visits or completed environmental investigations, but 
     very few monitor the outcomes for children and the corrective 
     measures taken in those properties found to have poisoned a 
     child. For example, eight states did not know how many lead-
     poisoned children needing follow-up care had been identified 
     in 1997 and 23 states did not know how many of their lead-
     poisoned children had actually received services.
       Only 15 states reported providing oversight to ensure that 
     all children identified as lead-poisoned receive appropriate 
     follow-up care, including case management and environmental 
     investigation services. Such oversight would be particularly 
     useful in the 24 states that rely on providers outside the 
     health department to provide case management services. Only 
     13 states indicated that they collected and tabulated data on 
     the identified source(s) of lead exposure from environmental 
     investigations.
       Tracking case management and environmental investigation 
     activities is not enough in itself. The ultimate measure of 
     effectiveness is reducing the child's lead exposure and blood 
     lead level. Case management and environmental investigation 
     programs should be thoroughly evaluated to identify programs 
     that are effective, as well as to identify problems that 
     require additional staff training, technical assistance, or 
     other attention. In particular, this survey suggests that 
     staff in many states could benefit from training in key 
     areas, such as program evaluation and Medicaid and insurance 
     reimbursement.
       States should establish the administrative capacity at 
     either the state or local level to track delivery of case 
     management and environmental investigation services to lead-
     poisoned children, to track outcomes of interest for 
     individual children, and to ensure that appropriate services 
     are provided to lead-poisoned children.
       CDC should require its CLPP grantee to report on case 
     management service delivery outcome measures in their 
     required reports. Such reporting would help build capacity 
     for tracking and begin to document the effectiveness of 
     program follow-up efforts.
       States should establish, collect, and report outcome 
     measures for case management.
       All states should collect and aggregate data on lead 
     sources, including the proximate cause(s) of lead exposure 
     identified through environmental investigation, and the lead 
     hazard control actions taken, along with relevant information 
     allowing characterization of the lead hazards (e.g., age and 
     condition of housing, renter or owner-occupied, source and 
     pathway of exposure, etc.)
       CDC requires its grantees to provide data through its 
     STELLAR database, but its data fields have proven to be 
     limiting, especially for non-paint sources, and many grantees 
     report their dissatisfaction with STELLAR. CDC should 
     consider moving to an alternative software package with 
     greater flexibility and easily available support. Until CDC 
     revises its requirements, states should use standard office 
     database software to keep these records.
       CDC should undertake or fund formal evaluations of state 
     case management and environmental investigation programs. 
     Programs should be given the tools and opportunity to meet 
     goals and improve performance. However, if state or local 
     programs are not able to achieve basic standards of 
     performance in follow-up of lead-poisoned children, federal 
     funding should be terminated.
       CDC should sponsor a system of peer evaluation for state 
     and local lead programs. A pear evaluation program would 
     allow state program staff to learn from and share with one 
     another, reinforcing the replication of innovative and 
     effective practices.

  The PRESIDING OFFICER (Mr. Craig). The Senator from Maine.
  Ms. COLLINS. Mr. President, I am very pleased to join my friend and 
colleague, Senator Jack Reed of Rhode Island, in discussing the passage 
of a resolution we introduced designating this week, October 24 through 
the 30th, as National Childhood Lead Poisoning Prevention Week.
  Senator Reed has been such a strong advocate and leader on lead 
poisoning issues. I have enjoyed working with him on this important 
public health issue.
  It is my hope the designation of this week as National Childhood Lead 
Poisoning Prevention Week will help to increase awareness of the 
significant dangers and prevalence of childhood lead poisoning across 
our Nation.
  Great strides have been made in the past 20 years to reduce the 
threat that lead poses to human health. Most notably, lead has been 
banned from many products, including residential paints, food cans, and 
gasoline. These commendable steps have significantly reduced the 
incidence of lead poisoning. But unfortunately, contrary to what many 
people think, the threat has not been eradicated. In fact, it remains 
and continues to imperil the health and well-being of our Nation's 
children. In

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fact, lead poisoning is the No. 1 environmental health threat to 
children in the United States.
  Even low levels of lead exposure can have serious developmental 
consequences, including reductions in IQ and attention span, reading 
and learning disabilities, hyperactivity and behavioral problems. The 
Centers for Disease Control and Prevention currently estimates that 
890,000 children, age 1 through 5, have blood levels of lead that are 
high enough to affect their ability to learn--nearly a million 
children.
  Today, the major lead poisoning threat to children is posed by paint 
that has deteriorated. Contrary to popular belief, it is the dust from 
deteriorating or disturbed paint, rather than paint chips, that is the 
primary source of lead poisoning. Unfortunately, it is all too common 
for older homes to contain lead-based paint, particularly if they were 
built before 1978. More than half of the entire housing stock and 
three-quarters of homes built before 1978, contain some lead-based 
paint. Paint manufactured prior to the residential lead paint ban often 
remains safely contained and unexposed for decades. But over time, 
often through remodeling or normal wear and tear, the paint can become 
exposed, contaminating the home with dangerous lead dust.
  The PRESIDING OFFICER. The Senator from Virginia is recognized.

                          ____________________