Medicaid: Elevated Blood Lead Levels in Children (Letter Report,
02/20/98, GAO/HEHS-98-78).

Pursuant to a congressional request, GAO provided information on the:
(1) degree to which blood lead levels associated with harmful health
effects exist among young children covered by Medicaid; and (2) extent
to which children covered by Medicaid have had screening blood lead
tests.

GAO noted that: (1) its analysis of the National Health and Nutrition
Examination Survey (NHANES) data shows that lead toxicity is a
significant problem for children receiving care under Medicaid; (2)
these children were more than three times as likely to have high levels
of lead in their blood as were children not receiving care under
Medicaid; (3) GAO estimates that more than half a million Medicaid
children--about 1 in every 12 children aged 1 through 5 in the
program--have harmful levels of lead in their blood; (4) despite the
Health Care Financing Administration's mandatory screening requirements
for children in these age groups, most Medicaid children had never been
checked for high lead levels; (5) for nearly two-thirds of the Medicaid
children identified through NHANES screenings as having high lead
levels, this was the first screening for lead they had ever received;
and (6) projected to the entire Medicaid population of children aged 1
through 5, this represents about 352,000 children who probably have high
levels of lead in their blood but have not been tested for it.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-98-78
     TITLE:  Medicaid: Elevated Blood Lead Levels in Children
      DATE:  02/20/98
   SUBJECT:  Children
             Health care programs
             Health statistics
             Health surveys
             Health hazards
IDENTIFIER:  Medicaid Program
             National Health and Nutrition Examination Survey
             
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Cover
================================================================ COVER


Report to the Ranking Minority Member, Committee on Government Reform
and Oversight, House of Representatives

February 1998

MEDICAID - ELEVATED BLOOD LEAD
LEVELS IN CHILDREN

GAO/HEHS-98-78

Blood Lead Levels in Medicaid Children

(108353)


Abbreviations
=============================================================== ABBREV

  CDC - Centers for Disease Control and Prevention
  HCFA - Health Care Financing Administration
  HHS - Department of Health and Human Services
  NHANES - National Health and Nutrition Examination Survey
  SUDAAN - Software for Survey Data Analysis

Letter
=============================================================== LETTER


B-279246

February 20, 1998

The Honorable Henry A.  Waxman
Ranking Minority Member
Committee on Government Reform and Oversight
House of Representatives

Dear Mr.  Waxman: 

High levels of lead in the blood--usually present as a result of
being around surfaces painted with lead-based paint--have been an
ongoing concern because high concentrations of lead in the body can
affect learning abilities and can produce severe health problems. 
The Department of Health and Human Services (HHS) has recently
released health survey data indicating that, while an estimated
890,000 U.S.  children aged 1 through 5 have high levels of lead in
their blood, the incidence of such high levels of lead is declining
markedly.  The Health Care Financing Administration (HCFA), the
agency responsible for administering the Medicaid program at the
federal level, is now reviewing the mandatory requirement for
screening for lead toxicity in Medicaid children.  As a joint federal
and state program, Medicaid provides medical care to about one-third
of all children aged 1 through 5 in the United States.\1

At your request, we are reviewing federal support for lead-poisoning
prevention programs, including the extent to which at-risk children
have been screened for lead toxicity.  In light of our ongoing work,
you asked us to provide you with our initial analysis of HHS's survey
data, focusing specifically on Medicaid children.  This letter
provides information on (1) the degree to which blood lead levels
associated with harmful health effects exist among young children
covered by Medicaid and (2) the extent to which children covered by
Medicaid have had blood lead screening tests.\2 At present, a blood
test is the only screening method available to identify children with
high blood lead levels. 

Our analysis is based on data from HHS's most recently released phase
of the National Health and Nutrition Examination Survey (NHANES).\3
This survey contains nationally representative information on the
health and nutritional status of the U.S.  population through direct
physical examinations and interviews.  The physical examinations
include a test for blood lead, and the interviews include questions
on various health, demographic, and nutritional characteristics,
including Medicaid coverage and whether the participant has been
screened for lead toxicity.  The most recent segment of NHANES was
based on a national sample of 15,427 persons 2 months and older (and
was conducted between 1991 and 1994).  Of the persons surveyed, 2,387
were children aged 1 through 5 years, of whom 984 were covered by
Medicaid.  The information we present on Medicaid beneficiaries is
only for children aged 1 through 5 because young children are most
vulnerable to the effects of lead toxicity.  Appendix I explains in
further detail our methodology for analyzing the NHANES data.  We
conducted this work from September 1997 to January 1998 in accordance
with generally accepted government auditing standards. 


--------------------
\1 Medicaid is a means-tested program for low-income persons
including families with children, pregnant women, and persons who are
aged, blind, or disabled.  In return for federal financial
participation, states agree to provide or arrange for the provision
of a number of screening services to members of this population under
age 21, including blood lead level assessments appropriate for age
and risk factors. 

\2 We are defining "screening" as a laboratory test for lead in
blood. 

\3 The NHANES has been conducted many times since 1960.  This
analysis is from the Third NHANES, Phase 2 (1991-94).  U.S. 
Department of Health and Human Services, Centers for Disease Control
and Prevention, National Center for Health Statistics, Third National
Health and Nutrition Examination Survey, 1988-1994, NHANES III
Laboratory and Youth Data Files (CD-ROM), Hyattsville, Md., 1996. 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

Our analysis of the NHANES data shows that lead toxicity is a
significant problem for children receiving care under Medicaid. 
These children were more than three times as likely to have high
levels of lead in their blood as were children not receiving care
under Medicaid.  We estimate that more than half a million Medicaid
children--about 1 in every 12 children aged 1 through 5 in the
program--have harmful levels of lead in their blood.  Despite HCFA's
mandatory screening requirements for children in these age groups,
most Medicaid children had never been checked for high lead levels. 
For nearly two-thirds of the Medicaid children identified through
NHANES screenings as having high lead levels, this was the first
screening for lead they had ever received.  Projected to the entire
Medicaid population of children aged 1 through 5, this represents
about 352,000 children who probably have high levels of lead in their
blood but have not been tested for it.\4


--------------------
\4 Our estimates represent the means.  Appendix II shows the upper
and lower limits of these estimates. 


   BACKGROUND
------------------------------------------------------------ Letter :2

Childhood lead poisoning has long been considered to be the most
serious environmental health threat to children in the United States,
estimated to cost society billions of dollars.  At extremely high
levels, lead can cause devastating health consequences, including
seizures, coma, and death.  At lower levels, lead can affect a
child's intelligence and ability to learn.  Young children are more
susceptible to lead poisoning because their developing nervous
systems are more vulnerable to injury and they absorb more lead than
adults.  One- and 2-year-old children are at greatest risk because of
normal hand-to-mouth activity and increasing mobility during the
second year of life, resulting in more access to lead hazards. 

In 1991, HHS established the goal of eliminating childhood lead
poisoning in the United States by 2011.  In conjunction with this
goal, the agency's Centers for Disease Control and Prevention (CDC)
issued guidelines calling for virtually all children aged 1 through 5
to be screened for lead toxicity.  In November 1997, citing a
declining trend of average blood lead levels and generally low rates
of screening, CDC revised its guidelines.\5 CDC's new guidelines
recommend that state health officials develop statewide plans for
childhood lead screening and better target children who are at
specific risk. 

In response to CDC's changing guidelines, HCFA is reconsidering its
Medicaid policy.  Federal Medicaid policy for screening children for
lead toxicity was established by the Omnibus Budget Reconciliation
Act of 1989, which required that Medicaid's early and periodic
screening, diagnostic, and treatment services include blood lead
level laboratory tests appropriate for age and risk factors.\6 In
1992, HCFA required that in line with CDC recommendations, Medicaid
children be screened for lead toxicity at a minimum at ages 1 and 2
for low-risk children and more frequently if they were determined to
be at higher risk.  CDC's new guidelines indicate that anticipated
changes in HCFA's policy may give the states the responsibility of
deciding whether all Medicaid children should be screened. 


--------------------
\5 On average, blood lead levels in the total population declined by
22 percent between the most recent segments of the NHANES.  The first
segment was conducted between 1988 and 1991, and the second was
conducted between 1991 and 1994. 

\6 Making such services available in compliance with the law does not
guarantee their provision. 


   THE PREVALENCE OF ELEVATED
   BLOOD LEAD LEVELS IS MUCH
   HIGHER FOR MEDICAID CHILDREN
------------------------------------------------------------ Letter :3

On the basis of NHANES data, CDC estimates that 890,000 children aged
1 through 5 in the United States have blood lead levels associated
with harmful effects on children's ability to learn.  CDC has set
this "harmful effects" level of lead toxicity at 10 or more
micrograms of lead per deciliter (g/dL) of blood.  At this
level, CDC considers blood lead levels to be "elevated" and
recommends that various actions be taken.  These actions differ
depending on the severity of the lead toxicity and include providing
family education on lead, follow-up testing, and clinical management
such as administering drugs to remove lead from the system. 

Applying CDC's definition of a harmful lead level to Medicaid
beneficiaries aged 1 through 5 in the NHANES, our analysis shows that
about 1 Medicaid child in every 12 had an elevated blood lead level. 
This rate was more than three times that of the non-Medicaid
population.  Specifically, about 9 percent of Medicaid children aged
1 through 5 had blood lead levels at 10 g/dL or greater,
compared to about 3 percent of the non-Medicaid population. 

NHANES data indicate that Medicaid children constitute the majority
of children with elevated blood lead levels.  Although Medicaid
children represented about one-third of the U.S.  population of
children aged 1 through 5, they represented about 60 percent of the
890,000 children with elevated blood lead levels. 

In addition, at least 83 percent of children with higher levels of
lead toxicity (20 g/dL or more) in the NHANES were covered
by Medicaid.  At this level, CDC recommends children receive more
intensive clinical management, including evaluations for
complications of lead poisoning, family lead education and referrals,
and follow-up testing.  CDC further recommends that treatment at this
level include environmental investigations to identify and control
sources of lead exposure. 


   FEW MEDICAID CHILDREN ARE
   SCREENED FOR BLOOD LEAD LEVELS
------------------------------------------------------------ Letter :4

Blood lead screening is an important element in eliminating childhood
lead poisoning, because in most cases there are no obvious symptoms
of elevated blood lead levels or lead poisoning.  Despite HCFA's
screening requirements, 81 percent of Medicaid children in the NHANES
had not been previously screened, based on the NHANES respondent
interviews. 

This screening rate was not sufficient to identify most Medicaid
children with excessive blood lead levels.  While Medicaid children
with lead toxicity had been screened at a higher rate than other
Medicaid children, a significant portion of children with elevated
blood lead levels had not been previously screened.  The survey
indicates that about 65 percent of the Medicaid children aged 1
through 5 with elevated blood levels had not been screened for blood
lead prior to receiving a screening as part of the survey.  From
these results, we estimate that 352,000 of the 535,000 Medicaid
children with elevated blood lead levels have not been screened. 

The NHANES data do not provide enough information to show how HCFA
should update its lead screening policy.  However, they do indicate
that the problem of lead toxicity is concentrated in the Medicaid
population and that the implementation of HCFA's mandatory screening
policy has been inadequate to identify the majority of children with
elevated lead levels.  The NHANES data do not allow us to determine
why screenings are not occurring or to examine follow-up treatment
and case management services for children found with elevated blood
lead levels.  As we agreed with your staff, we are continuing our
analysis of these and other issues related to federal support for
lead-poisoning prevention programs in preparation for our final
report to you later this year. 


   AGENCY COMMENTS
------------------------------------------------------------ Letter :5

We provided a draft of this report to the Secretary of HHS for review
and comment; however, we did not receive comments in time for
publication.  CDC and HCFA officials provided technical comments that
we incorporated as appropriate. 


---------------------------------------------------------- Letter :5.1

As agreed with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 7 days
from the date of this letter.  At that time we will send copies of
this report to the Secretary of HHS and other interested parties.  We
will also make copies available to others on request. 

The information contained in this report was developed by Frank
Pasquier, Assistant Director, Tim Clouse, and Katherine Iritani. 
Please contact me at (202) 512-6543 or Frank Pasquier at (206)
287-4861 if you or your staff have any questions. 

Sincerely yours,

Bernice Steinhardt
Director, Health Services Quality
 and Public Health Issues


METHODOLOGY AND USE OF NHANES DATA
=========================================================== Appendix I

The NHANES III is designed to provide national estimates of health
and nutritional status of the civilian noninstitutionalized
population of the United States aged 2 months and older.  It is the
latest in the NHANES series (conducted many times since 1960) and was
conducted in two phases:  Phase 1 ran from 1988 to 1991 and Phase 2
ran from 1991 to 1994.  Details of the survey design and
questionnaires are published in the NHANES III Plan and Operation
Reference manual.\7

The NHANES oversampled selected subpopulations to increase the
reliability of estimates.  These subpopulations were children aged 2
months through 5 years, blacks, Mexican Americans, and persons aged
60 or older.  While NHANES was not designed to specifically sample
the Medicaid population, the NHANES III, Phase 2, Medicaid child
population estimates are comparable to those published by HCFA. 
Specifically, the NHANES III, Phase 2, estimate for Medicaid children
aged 1 through 5 years between 1991 and 1994 was 6,274,000.  The HCFA
estimate for fiscal year 1993 (the midpoint for NHANES III, Phase 2)
was 6,632,000. 

The variables and population estimates that we selected were
consistent with those CDC used in its publication of the estimates
for the prevalence of elevated blood lead levels among the population
at large.\8 Of the 15,427 persons who were examined in NHANES III,
Phase 2, there were 2,387 children aged 1 through 5 years whose
survey results contained data on their blood lead levels and Medicaid
status.  NHANES III, Phase 2, questions regarding blood lead testing
were answered by the respondents for the 2,351 of the children in our
sample.  We excluded children whose survey results were missing
responses to questions whenever we used those questions in our
analysis. 

We excluded from our analysis some children who may be eligible for
Medicaid in order to present conservative estimates of the prevalence
of elevated blood lead levels among Medicaid children.  The children
excluded were living in a family in which at least one other person
was receiving Medicaid benefits, but the NHANES survey data did not
show that the specific child selected for NHANES was receiving
Medicaid benefits. 

We reviewed the NHANES design, data reliability checks, and reporting
guidelines before using these data.  We also compared the
NHANES-computed estimates with Bureau of the Census population
estimates and Health Care Financing Administration (HCFA) reports on
the Medicaid population.  From these reviews and comparisons, we
conclude that NHANES data are sufficiently reliable to be used in
meeting our objectives. 


--------------------
\7 Plan and Operation of the Third National Health and Nutrition
Examination Survey, 1988-94, National Center for Health Statistics,
Vital Health Stat.  1, Vol.  32 (1994). 

\8 Centers for Disease Control and Prevention, "Update:  Blood Lead
Levels--United States, 1991-1994," MMWR, Vol.  46 (1997), pp. 
141-46.  Erratum:  MMWR, Vol.  46, No.  7 (1997), p.  607. 


UPPER AND LOWER LIMITS FOR
ESTIMATES
========================================================== Appendix II

The tables in this appendix show the estimates made from the National
Health and Nutrition Examination Survey (NHANES) data, together with
the confidence intervals of these estimates.  There is a 5-percent
chance that the actual number is outside these limits.\9 While the
comparatively small sample size of some subpopulation categories
results in a relatively wide range between the high and low
estimates, the numbers of children at the low ends of these estimates
remains substantial. 



                         Table II.1
          
           Estimated Number of Children Aged 1-5

                                  Estimate
                  ----------------------------------------
Number                    Mean   Lower limit   Upper limit
----------------  ------------  ------------  ------------
Children          20,179,000\a    16,900,000    23,458,000
Medicaid             6,274,000     5,459,000     7,088,000
 children
----------------------------------------------------------
\a NHANES benchmarked the means to those used by the Bureau of Census
1993 undercount adjusted Current Population Survey. 



                         Table II.2
          
           Estimated Number of Children Aged 1-5
              With Elevated Blood Lead Levels\

                                  Estimate
                  ----------------------------------------
Number with
elevated blood
lead levels               Mean   Lower limit   Upper limit
----------------  ------------  ------------  ------------
All children           890,000       526,000     1,254,000
Medicaid               535,000       290,000       780,000
 children
Non-Medicaid           355,000       157,000       553,000
 children
----------------------------------------------------------
Note:  According to the definition of the Centers for Disease Control
and Prevention (CDC), elevated blood lead levels are at 10
g/dL of blood or greater. 



                         Table II.3
          
           Estimated Number of Children Aged 1-5
          Screened for Elevated Blood Lead Levels

                                  Estimate
                  ----------------------------------------
Number screened
for elevated
blood lead
levels                    Mean   Lower limit   Upper limit
----------------  ------------  ------------  ------------
All children         2,321,000     1,510,000     3,131,000
Medicaid             1,127,000       648,000     1,696,000
 children
Non-Medicaid         1,194,000       692,000     1,787,000
 children
----------------------------------------------------------
Note:  These estimates are based on information reported by the
NHANES respondents in the interview portion of the survey. 



                         Table II.4
          
           Estimated Number of Children Aged 1-5
            With Undetected Elevated Blood Lead
                           Levels

                                  Estimate
                  ----------------------------------------
Number with
elevated blood
lead levels and
not previously
screened                  Mean   Lower limit   Upper limit
----------------  ------------  ------------  ------------
All children           565,000       344,000       786,000
Medicaid               352,000       270,000       434,000
 children
Non-Medicaid           213,000       131,000       295,000
 children
----------------------------------------------------------
Note:  Children with elevated blood lead levels who had a history of
a prior blood lead test were excluded from these estimates.  The
NHANES data did not identify whether these children were in the
process of being treated for an existing blood lead level condition
or whether NHANES was actually identifying a more recent undetected
exposure.  To the extent that the latter situation exists, the
estimates of undetected cases could be increased.  For this reason,
our estimate of children with undetected elevated blood lead levels
is conservative. 


--------------------
\9 Means, proportions, and standard errors were obtained by using
Software for Survey Data Analysis (SUDAAN), as suggested in the
NHANES III Analytic and Reporting Guidelines. 


*** End of document. ***