Lead Poisoning: Federal Health Care Programs Are Not Effectively Reaching
At-Risk Children (Chapter Report, 01/15/99, GAO/HEHS-99-18).

Pursuant to a congressional request, GAO examined: (1) the risk of lead
poisoning faced by young children served by federal health care
programs; (2) the extent to which children served by these programs have
been screened for this condition; (3) key reasons why screenings may not
be occurring; and (4) problems that federal health care programs face in
ensuring that children who have harmful lead levels in their blood
receive timely follow-up treatment and other services.

GAO noted that: (1) the children served by federal health programs
remain at significant risk for elevated blood lead levels; (2)
three-fourths of all the children found to have an elevated blood lead
level in the Centers for Disease Control and Prevention (CDC) 1991-94
survey were enrolled in Medicaid or the Special Supplemental Food
Program for Women, Infants and Children (WIC) or were within the target
population for the Health Center Program; (3) this equates to nearly
700,000 children nationwide; (4) more than 8 percent of the surveyed
children aged 1 through 5 who were served by federal health care
programs had a harmful blood lead level, a rate almost five times the
rate for children who were not in these federal programs; (4) despite
federal policies, most children in federal health care programs have not
been screened; (5) for nearly two-thirds of the surveyed children aged 1
through 5 identified by CDC as having elevated lead levels, the blood
lead test conducted as part of the CDC survey was the first such test
they had received; (6) projecting these results nationally, more than
400,000 U.S. children in federal health care programs have undetected
elevated blood lead levels; (7) other data that GAO analyzed for
specific federal health programs tended to corroborate the overall low
screening rates reported in CDC's survey and also showed that screening
rates vary greatly from state to state and locality to locality; (8)
screening is often not occurring because federal screening policies are
largely not monitored at the federal and state levels; (9) one
underlying reason for low screening rates is the widespread belief among
providers that lead exposure is no longer a problem in their
communities; (10) most state officials GAO contacted lacked reliable,
representative data on the prevalence of elevated blood lead levels and
the extent of screening in their states; (11) another problem is that
many children are not receiving adequate preventive health care
services, visiting the doctor only when they are sick; (12) follow-up
treatment for children identified with elevated blood lead levels is
complex and potentially resource intensive; and (13) at health centers
and state and local health departments visited across the country, GAO
found wide variation in the extent of timely follow up.

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

 REPORTNUM:  HEHS-99-18
     TITLE:  Lead Poisoning: Federal Health Care Programs Are Not 
             Effectively Reaching At-Risk Children
      DATE:  01/15/99
   SUBJECT:  Health hazards
             Health surveys
             Health care services
             Health centers
             Medical examinations
             Toxic substances
             Children
             Health care programs
             Disadvantaged persons
IDENTIFIER:  Early and Periodic Screening, Diagnosis, and Treatment 
             Program
             National Health and Nutrition Examination Surveys
             Special Supplemental Food Program for Women, Infants, and 
             Children
             Medicaid Program
             Childhood Lead Poisoning Prevention Program
             WIC
             
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Cover
================================================================ COVER


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

January 1999

LEAD POISONING - FEDERAL HEALTH
CARE PROGRAMS ARE NOT EFFECTIVELY
REACHING AT-RISK CHILDREN

GAO/HEHS-99-18

Lead Poisoning

(108334)


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

  ATSDR - Agency for Toxic Substances and Disease Registry
  CDC - Centers for Disease Control and Prevention
  EPA - Environmental Protection Agency
  EPSDT - Early and Periodic Screening, Diagnosis, and Treatment
  HCFA - Health Care Financing Administration
  HHS - Department of Health and Human Services
  HRSA - Health Resources and Services Administration
  HUD - Department of Housing and Urban Development
  NHANES - National Health and Nutrition Examination Survey
  USDA - Department of Agriculture
  WIC - Special Supplemental Nutrition Program for Women, Infants,
     and
  Children

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


B-277635

January 15, 1999

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

Dear Mr.  Waxman: 

This report responds to your request that we review federal
activities for ensuring that at-risk children receive screening and
treatment for lead poisoning.  In particular, this report addresses
the risk of lead poisoning faced by children served by federal health
care programs, the extent to which children served by these programs
have been screened for this condition, reasons why screenings may not
be occurring, and problems faced by federal health care programs in
ensuring that children who have been identified as having harmful
lead levels in their blood receive timely follow-up treatment and
other services. 

As arranged with your office, unless you publicly announce its
contents earlier, we plan no further distribution of this report
until 30 days after the date of this letter.  We will then send a
copy to the Secretary of Health and Human Services and others who are
interested. 

Please contact me at (202) 512-7119 if you or your staff have any
questions.  Other GAO contacts and major contributors to this report
are listed in appendix IX. 

Sincerely,

Bernice Steinhardt
Director, Health Services Quality
 and Public Health Issues


EXECUTIVE SUMMARY
============================================================ Chapter 0


   PURPOSE
---------------------------------------------------------- Chapter 0:1

Lead poisoning, a preventable condition, is one of the most serious
environmental health threats to children in the United States.  Among
young children, elevated blood lead levels impair mental and physical
development.  Because most children display no obvious symptoms, the
best way to detect the condition is through a screening blood test. 
After administering such tests to a representative sample of children
aged 1 through 5 as part of a nationwide health survey conducted
between 1991 and 1994, the Department of Health and Human Services
(HHS) estimated in 1997 that about 890,000, or 4.4 percent, of the
children in that age group had harmful levels of lead in their blood. 

Children in low-income families who live in older housing with
deteriorating lead-based paint are at high risk for lead poisoning. 
The federal government, as a major source of health care funding for
the low-income population, has set policies that young children who
receive federally supported health care should receive lead screening
services.  The extent to which federal health care programs are
actually screening and providing adequate treatment services to
children found with harmful blood lead levels, however, remains
unknown.  Consequently, the ranking minority member of the House
Committee on Government Reform asked GAO to address (1) the risk of
lead poisoning faced by young children served by federal health care
programs, (2) the extent to which children served by these programs
have been screened for this condition, (3) key reasons why screenings
may not be occurring, and (4) problems that federal health care
programs face in ensuring that children who have harmful lead levels
in their blood receive timely follow-up treatment and other services. 


   BACKGROUND
---------------------------------------------------------- Chapter 0:2

Until recently, the Centers for Disease Control and Prevention (CDC),
the HHS agency recommending U.S.  policy for lead screening and
treatment, has stated that virtually all children ages 1 through 5
should receive a blood lead test.  However, national health surveys
that CDC conducts periodically have shown a marked decline in the
prevalence of elevated blood lead levels in recent years, attributed
primarily to the regulatory ban on lead in gasoline and lead-soldered
food cans.  The surveys, most recently conducted from 1991 through
1994, involve physical examinations and interviews for a
representative sample of virtually all age groups across the country. 
The physical exams include a blood lead test, and the interviews
include questions about each child's participation in federal health
care programs and their lead screening history.  From the most recent
survey sample, CDC estimated in 1997 that 890,000 children aged 1
through 5 had elevated blood lead levels.  CDC has set the level of
concern for lead toxicity at 10 or more micrograms of lead per
deciliter (g/dl) of blood.  Average blood lead levels for
children aged 1 through 5 declined from 15 g/dl during 1976
through 1980 to 2.7 g/dl during 1991 through 1994.  Citing
this trend, CDC in 1997 changed its lead screening guidelines to
recommend that health officials develop statewide plans that target
children who are at specific risk. 

However, HHS policies to screen children participating in federal
health care programs still remain in place.  The federal government
has several health care programs serving low-income children that may
provide blood lead screenings.  Those included in GAO's review are as
follows: 

  -- Medicaid, a joint federal and state program, is administered at
     the federal level by the Health Care Financing Administration. 
     This health care financing program for low-income families
     covers about one-third of the nation's children aged 1 through
     5. 

  -- The Health Center Program, administered by the Health Resources
     and Services Administration, awards grants to more than 3,000
     sites across the nation to provide primary health care services
     in medically underserved areas.  Children served by
     participating health centers include those covered by Medicaid
     and an estimated 14 percent of the nation's uninsured children. 

GAO also reviewed policies for the Special Supplemental Nutrition
Program for Women, Infants, and Children (WIC), administered by the
Department of Agriculture, which serves low-income pregnant women and
young children at nutritional risk.  Research has shown that children
at nutritional risk are especially susceptible to lead poisoning.  In
addition to delivering nutrition services in more than 2,000 local
agencies nationwide, this program helps women and children receive
preventive health services such as lead screening. 


   RESULTS IN BRIEF
---------------------------------------------------------- Chapter 0:3

GAO's analysis of CDC's most recent blood lead level and screening
survey data shows that the children served by federal health care
programs remain at significant risk for elevated blood lead levels. 
Three-fourths of all the children aged 1 through 5 found to have an
elevated blood lead level in CDC's 1991-94 survey were enrolled in
Medicaid or WIC or were within the target population for the Health
Center Program.  This equates to nearly 700,000 children nationwide. 
More than 8 percent of the surveyed children aged 1 through 5 who
were served by federal health care programs had a harmful blood lead
level, a rate almost five times the rate for children who were not in
these federal programs. 

Despite federal policies, most children in or targeted by federal
health care programs have not been screened.  For nearly two-thirds
of the surveyed children aged 1 through 5 identified by CDC as having
elevated lead levels, the blood lead test conducted as part of the
CDC survey was the first such test they had received.  Projecting
these results nationally, more than 400,000 U.S.  children in or
targeted by federal health care programs have undetected elevated
blood lead levels.  Other data that GAO analyzed for specific federal
health programs tended to corroborate the overall low screening rates
reported in CDC's survey and also showed that screening rates vary
greatly from state to state and locality to locality. 

Screening is often not occurring because federal screening policies
are largely not monitored at the federal and state levels.  Within
Medicaid, for example, only about half of all 51 state programs
(including the District of Columbia) that GAO surveyed had screening
policies in line with federal policy in the frequency of required
screenings, and many states did not monitor providers' lead screening
activities.  One underlying reason for low screening rates is the
widespread belief among providers that lead exposure is no longer a
problem in their communities.  Most state officials GAO contacted
lacked reliable, representative data on the prevalence of elevated
blood lead levels and the extent of screening in their states. 
Another problem is that many children are not receiving adequate
preventive health care services, visiting the doctor only when they
are sick. 

Follow-up treatment for children identified with elevated blood lead
levels is complex and potentially resource intensive.  Recommended
services include follow-up testing, care coordination, and
investigations to determine the source of lead exposure, but there
are few national data to reliably show the extent to which services
are provided to lead-poisoned children.  At health centers and state
and local health departments visited across the country, GAO found
wide variation in the extent of timely follow-up.  Specific problems
hindering the delivery of care included providers' missing
opportunities to perform follow-up tests and children's not returning
for follow-up care.  Another problem is that most state Medicaid
programs do not reimburse for key treatment services. 


   PRINCIPAL FINDINGS
---------------------------------------------------------- Chapter 0:4


      ELEVATED BLOOD LEAD LEVELS
      REMAIN A SIGNIFICANT PROBLEM
      FOR CHILDREN SERVED BY
      FEDERAL HEALTH CARE PROGRAMS
-------------------------------------------------------- Chapter 0:4.1

GAO's analysis of CDC's nationally representative survey data shows
that a disproportionate number of the children who have elevated
blood lead levels are served by federal health care programs. 
Although about 40 percent of surveyed children aged 1 through 5 were
receiving benefits from Medicaid or WIC or were within the target
population of the Health Center Program, more than 77 percent of the
children who had elevated blood lead levels in the survey were in or
targeted by these programs.  This represents 688,000 of the 890,000
children aged 1 through 5 nationwide who were projected to have
elevated levels of lead in their blood. 

Among surveyed children aged 1 through 5 enrolled in or targeted by
federal health care programs, the rate (or prevalence) of elevated
blood lead levels was 8.4 percent.  This rate was nearly five times
the rate for children not in these programs.  Analyzing data by
individual federal health care programs, GAO found that among
children aged 1 through 5 enrolled in Medicaid, the prevalence was
greater than 8 percent.  For children aged 1 through 5 in low-income
and uninsured families (and thus within the target population of the
Health Center Program), the prevalence was 6 percent.  For children
aged 1 through 5 receiving WIC benefits, the prevalence was almost 12
percent. 


      MOST CHILDREN SERVED BY
      FEDERAL HEALTH CARE PROGRAMS
      ARE NOT BEING SCREENED FOR
      LEAD
-------------------------------------------------------- Chapter 0:4.2

The CDC survey and Medicaid data also show that children served by
federal health care programs are largely not receiving the lead
screenings required by federal policies.  Reports from parents,
guardians and other respondents in CDC's 1991-94 survey show that
less than 20 percent of children served by federal health care
programs had been screened for lead before participating in the
survey.  A separate analysis of Medicaid billing data for 1994 and
1995 showed a similar overall screening rate in Medicaid
fee-for-service programs for the 15 states where data were available. 

GAO also found that screening has not been sufficient to identify
most of the children who were in federal health care programs and had
elevated blood lead levels.  CDC survey data show that most of those
projected to have elevated blood lead levels have not been so
identified.  In other words, the approximate size of the group is
known, but the specific children are not.  The statistical
projections from the survey indicate that of the estimated 688,000
children aged 1 through 5 who have elevated blood lead levels and are
in or targeted by federal health care programs, more than 400,000
have never been screened. 

Medicaid data and GAO reviews of health center medical records
demonstrate that screening varies from location to location.  Billing
data from 15 state Medicaid fee-for-service programs show that
state-level screening for 1- and 2-year-old children enrolled in
Medicaid for a year or longer ranged from less than 1 percent to a
high of 46 percent.  GAO samples of medical records at seven
federally supported health centers across the country, selected
because they served high numbers of children in Medicaid and had high
numbers of old houses in their area, showed that most of the selected
health centers were screening at higher rates than those found in the
CDC survey and the 15-state Medicaid information.  However, rates
still varied--ranging from no children screened at one health center
to all children screened at two centers. 


      SCREENING RATES ARE AFFECTED
      BY LACK OF OVERSIGHT AND
      OTHER PROBLEMS
-------------------------------------------------------- Chapter 0:4.3

Several problems contribute to the low screening rates found in
national and state data.  First, federal lead screening policies are
often not followed or monitored, as exemplified by the partial
implementation of policies by many state and local programs.  States
have often adopted less rigorous policies, and even these policies
are often not monitored.  A GAO nationwide survey of Medicaid
programs found that almost half of the states had adopted policies
less rigorous than the federal policy for screening children in
Medicaid (in the frequency of required screenings), and more than
one-third were not monitoring providers' lead screening activities. 
Similarly, three of seven health centers that GAO visited were not
complying with all federal lead screening policies.  In the states
that GAO reviewed, reported screening was highest where states had
their own screening laws together with mechanisms to ensure screening
(such as requiring proof of screening as a condition of entering
daycare or school). 

GAO's review and other research point to two other--and more
underlying--problems that hinder screening.  The first is that many
physicians perceive that lead poisoning is not prevalent or serious. 
A second problem is that many children are still not receiving
preventive health care services and hence miss the opportunity for
blood lead screenings.  For example, health officials said a
significant problem was that some families do not seek preventive
care services, visiting providers only when children are sick. 

Better state and local data on the prevalence of, and screening for,
elevated blood lead levels and improved federal, state, and local
coordination between lead screening and other preventive care
activities are potential areas of action to improve screening.  Most
state Medicaid agencies and many state lead poisoning prevention
programs GAO contacted lacked reliable data showing the prevalence of
elevated blood lead levels or the extent of screening of children
within the Medicaid program or the state.  HHS initiatives to improve
the extent to which children receive other preventive health care
services, such as immunizations, could provide avenues and models for
improving screening if initiatives were coordinated.  While the
increasing number of Medicaid managed care arrangements provides
another opportunity to improve screening, recent research indicates
that more than half of state Medicaid managed care contracts have not
addressed lead screening responsibilities. 


      SEVERAL PROBLEMS HINDER
      EFFORTS TO PROVIDE TIMELY
      TREATMENT AND FOLLOW-UP
      SERVICES
-------------------------------------------------------- Chapter 0:4.4

For many children who have elevated blood lead levels, several
problems hinder the efforts of federally supported health care
programs to ensure timely treatment and follow-up services.  No
national database exists for reliably determining the extent to which
recommended follow-up services--such as follow-up testing to ensure
that levels decline, care coordination, and environmental
investigations to determine the source of lead--are actually
provided.  The information GAO was able to develop from health
centers and health departments in seven states, while limited,
indicates gaps in providing needed follow-up, including timely
retesting to determine if the problem is continuing. 

GAO's medical record review and interviews with health center and
health department officials found barriers to providing follow-up
testing and other services to children who have elevated blood lead
levels, including the problem of providers missing opportunities to
perform timely follow-up tests and difficulties in tracking a
transient population of children.  Another key problem hindering the
provision of follow-up services was policy issues related to the
resource-intensiveness of recommended treatments for children who
have elevated blood lead levels.  Federal Medicaid law states that
Medicaid's Early and Periodic Screening, Diagnosis, and Treatment
program services must cover treatment or other forms of medical
assistance necessary to correct or ameliorate conditions identified
through screens, but because lead poisoning is an environmentally
caused condition, determining appropriate "medical treatments" for
elevated blood lead levels can be difficult.  GAO's review found that
many states are not covering follow-up services considered important
to treat a child who has an elevated lead level.  For example, while
HHS has for years indicated that lead investigation services are
integral to treating a lead-poisoned child, GAO's survey shows that
less than half the state Medicaid programs have policies to pay for
such services.  Most programs also do not have formal agreements with
other agencies coordinating the provision of follow-up services. 
Such formal coordination may be increasingly important as more
children are covered by Medicaid managed care, but recent research
indicates that Medicaid agencies have largely not considered how
managed care providers will need to work with others to provide
follow-up services to children who have elevated blood lead levels. 


   RECOMMENDATIONS
---------------------------------------------------------- Chapter 0:5

Specific recommendations to the Secretary of HHS for improving
federal support for lead poisoning prevention include (1) developing
better state and local information about the extent to which children
have elevated blood lead levels, (2) facilitating and monitoring
screening for children in federal health care programs, (3) improving
managed care contracts, (4) clarifying what services should be
available to children identified as having elevated blood lead
levels, and (5) enhancing federal efforts to coordinate lead
screening and treatment activities with those of other programs
serving at-risk children. 


   AGENCY COMMENTS
---------------------------------------------------------- Chapter 0:6

In its written response to a draft of this report, HHS indicated
general agreement with the recommendations and discussed steps that
were planned or under way to implement many of them.  The response
indicated that HHS was committed to ensuring that children served by
federal health care programs receive lead screening and necessary
treatment services.  HHS' response also made a number of suggestions
regarding the wording in the draft.  These suggestions have been
incorporated into the report where appropriate. 


INTRODUCTION
============================================================ Chapter 1

Despite dramatic reductions in blood lead levels over the past 20
years, lead poisoning continues to be a significant health risk for
young children.  Many children, especially those living in older
housing or who are poor, are still being harmed by exposure to lead. 
The Centers for Disease Control and Prevention (CDC) estimates that
890,000 children aged 1 through 5 in the United States have blood
lead levels associated with harmful effects on their ability to
learn.  Lead poisoning has long been considered to be the most
serious environmental health threat to children in the United States. 


   THE PROBLEM OF LEAD EXPOSURE IN
   CHILDREN
---------------------------------------------------------- Chapter 1:1

Lead is highly toxic and affects virtually every system of the body. 
At extremely high levels, lead can cause coma, convulsions, and
death.  At lower levels, studies have shown that lead can cause
reductions in IQ and attention span, reading and learning
disabilities, hyperactivity, and behavioral problems.  Relatively low
lead levels are typically not accompanied by overt, identifiable
symptoms.  Because most children who have elevated blood lead levels
have no obvious symptoms, a blood test is the best screening method
to identify harmful conditions. 

Lead is most hazardous to the nation's roughly 24 million children
under the age of 6, whose still-developing nervous systems are
particularly vulnerable to lead and whose normal play activities
expose them to lead-contaminated dust and soil.  One- and 2-year-old
children are at greatest risk because of normal hand-to-mouth
activity and the greater mobility during the second year of life that
gives them more access to lead hazards. 

New and increased knowledge of the health effects of exposure to lead
has led to concern about lead at levels once considered safe.  In
October 1991, the Department of Health and Human Services (HHS)
revised its level of concern for lead poisoning from the previous
threshold of 25 micrograms of lead per deciliter of blood
(g/dl) to 10 g/dl.  This change was based on
scientific evidence indicating that adverse health effects such as
impaired learning can occur at levels as low as 10 g/dl.\1
At this level, CDC, the HHS agency responsible for recommending U.S. 
policy for screening young children for lead poisoning, considers
blood lead levels to be "elevated" and recommends various actions. 


--------------------
\1 The National Research Council's Committee on Measuring Lead in
Critical Populations generally concurred with CDC in the selection of
10 g/dl as the concentration of concern in children. 
According to the committee, evidence is growing that even very small
exposure to lead can produce subtle effects in humans.  Therefore, as
lead toxicity becomes better understood, future guidelines may
establish an even lower level of concern.  See National Research
Council, Measuring Lead Exposure in Infants, Children, and Other
Sensitive Populations (National Academy Press, 1993). 


   PREVALENCE HAS DECLINED
   MARKEDLY, BUT MANY CHILDREN ARE
   STILL AFFECTED
---------------------------------------------------------- Chapter 1:2

While the prevalence of children who have elevated lead levels and
the average blood lead levels for the population as a whole have
declined dramatically over the past two decades, the number of
children who have elevated blood lead levels is still significant. 
Between the late 1970s and early 1990s, the prevalence of U.S. 
children aged 1 through 5 years who had elevated blood lead levels
dropped from 88 percent to 4.4 percent.  HHS and others consider the
decline in blood lead levels, associated with the regulatory and
voluntary bans on the use of lead in gasoline, household paint, food
and drink cans, and plumbing systems, to be a major achievement. 
Despite this achievement, however, CDC estimated in 1997 that about
890,000 children aged 1 through 5 had elevated blood lead levels.\2

Research also indicates that the risk for lead exposure remains
disproportionately high for some groups, including children who are
poor, non-Hispanic black, or Mexican American or are living in large
metropolitan areas or in older housing.  Identifying these children
and ensuring that they receive the services they need is a
significant public health challenge. 


--------------------
\2 Chapter 2 discusses how CDC made this estimate. 


   SOURCES OF LEAD EXPOSURE
---------------------------------------------------------- Chapter 1:3

Children in the United States are exposed to lead primarily by the
normal activity of putting their hands, toys, or other objects in
their mouths and, to a lesser extent, through inhalation.  Because
lead is ubiquitous in industrial societies, there are many sources
and pathways of lead exposure. 

Since lead has been removed from gasoline and food cans, CDC believes
that its foremost source in the environment of young children is
lead-based house paint.  Other major sources are lead-contaminated
dust and soil.  House dust is often contaminated by lead-based paint
that is peeling or deteriorating or disturbed during home renovation
or the preparation of painted surfaces for repainting without proper
safeguards.  Soil contamination can be traced back to deteriorating
exterior paint or past widespread use of leaded gasoline. 

Lead was a major ingredient in most interior and exterior oil house
paint before 1950 and was still used in some paints until 1978, when
the residential use of lead paint was banned.  The Department of
Housing and Urban Development (HUD) estimates that three-quarters of
pre-1980 housing units contain some lead-based paint, and the
likelihood, extent, and concentration of lead-based paint increase
with the age of the building.  In 1995, a federal task force on
lead-based paint in the United States estimated that, in all
likelihood, somewhere between 5 million and 15 million housing units
(of around 90 million occupied units nationwide) contained lead-based
paint hazards, of which only a portion were occupied by families with
children under age 6 at any given time.\3 However, because families
with young children--particularly those in rental housing--tend to
move frequently, far more units are occupied by children under age 6
than is shown by the point-in-time estimates of these units. 

Other, usually less common, sources of lead in a child's environment
include lead-contaminated drinking water (where lead solder and
sometimes lead pipes were used in the municipal water system, in the
child's home, or both), imported ceramic tableware with lead glaze,
old and imported toys or furniture painted with lead-based paint, the
clothing of parents whose work or hobby involves high levels of lead,
and even home remedies used by some ethnic groups. 


--------------------
\3 The Lead-Based Paint Hazard Reduction and Financing Task Force was
created under title X of the Housing and Community Development Act of
1992.  The task force was created to make recommendations on
lead-based paint hazard reduction and financing.  See Putting the
Pieces Together:  Controlling Lead Hazards in the Nation's Housing,
Report of the Lead-Based Paint Hazard Reduction and Financing Task
Force, HUD-1547-LBP (Washington, D.C.:  July 1995). 


   FEDERAL GOALS FOR REDUCING
   CHILDHOOD LEAD POISONING
---------------------------------------------------------- Chapter 1:4

Recognizing that tackling the problem of lead poisoning in children
will be a long-term effort, HHS published a strategic plan in 1991
calling for the elimination of childhood lead poisoning in 20
years--by the year 2011.\4 The strategic plan stated that increased
childhood lead poisoning prevention activities and national
surveillance for elevated lead levels are essential parts of a
national strategy to eliminate childhood lead poisoning.  HHS
reiterated its commitment to eliminating childhood lead poisoning by
2011 by including it as one of the objectives for CDC in its fiscal
year 1999 performance plan to the Congress\5 . 

Among its department-wide Healthy People 2000 objectives, HHS also
established goals to (1) have no children under age 6 with blood lead
levels exceeding 25 g/dl, and (2) have no more than 300,000
children under age 6 with blood lead levels exceeding 15
g/dl by 2000.\6 For its Healthy People 2010 objectives, HHS
has drafted a more ambitious goal than that established for 2000:  No
children aged 1 through 5 should have blood lead levels exceeding 10
g/dl.\7


--------------------
\4 Strategic Plan for the Elimination of Childhood Lead Poisoning
(Washington, D.C.:  HHS, 1991). 

\5 HHS, CDC, Fiscal Year 1999 Justification of Estimates for
Appropriations Committees (Washington, D.C.:  n.d.). 

\6 National Center for Health Statistics, Healthy People 2000 Review
1995-96 (Hyattsville, Md.:  Public Health Service, 1996). 

\7 The Healthy People 2010 initiative was in draft form at the time
of our review. 


      MANY FEDERAL AGENCIES ARE
      INVOLVED IN IDENTIFYING AND
      TREATING CHILDHOOD LEAD
      POISONING
-------------------------------------------------------- Chapter 1:4.1

Reflecting the complexity of childhood lead exposure and treatment,
numerous federal agencies have responsibilities for screening and
treatment.  Within HHS, these activities are centered on the
guidelines and grant programs of CDC, the Medicaid program
administered by the Health Care Financing Administration (HCFA), and
the health centers funded by the Health Resources and Services
Administration (HRSA). 

  -- CDC is the federal agency responsible for issuing
     recommendations for screening and treating young children for
     lead poisoning.  CDC gathers information on the extent of lead
     poisoning under the National Health and Nutrition Examination
     Survey (NHANES), a survey that gathers nationally representative
     data on the health and nutrition of the U.S.  population through
     direct physical examinations and interviews.  CDC also
     administers the Childhood Lead Poisoning Prevention and
     Surveillance Grant Program, awarding about $27 million in grants
     to more than 53 state and local public health departments in
     fiscal year 1998.  The CDC grant program was authorized by the
     Lead Contamination Control Act of 1988 and was amended by the
     Preventive Health Amendments of 1992.  CDC is required to report
     annually to the Congress on the number of children screened, the
     age and racial or ethnic status of the children screened, the
     severity of the extent of children's blood lead levels, and the
     sources of payment for the screenings. 

  -- Medicaid is a major health care financing program for low-income
     families.  As a joint federal and state program, Medicaid funds
     medical care for about one-third of all children aged 1 through
     5 in the United States.  HCFA's Medicaid policy for addressing
     childhood lead poisoning prevention was established by the
     Omnibus Budget Reconciliation Act of 1989, which required that
     Medicaid's Early and Periodic Screening, Diagnosis, and
     Treatment (EPSDT) services include blood lead laboratory tests
     appropriate for age and risk factors.\8 EPSDT services also
     include treatment or other forms of medical assistance for
     children who have elevated blood lead levels.  While some
     Medicaid services are provided under a traditional
     fee-for-service arrangement, at least 40 states also contracted
     with managed care organizations to provide health care services
     to some children covered by Medicaid in 1997.\9

  -- HRSA's Health Center Program supports more than 3,000 health
     center sites that provide primary care services, including lead
     screening and treatment, in medically underserved areas.\10
     Federal funding for the Health Center Program exceeded $820
     million in fiscal year 1998.  The Public Health Service Act
     defines required primary health services for health centers as
     including screenings for elevated blood lead levels.  The act
     requires health centers to provide these services to all
     residents of the area served by a center, and the centers'
     target population includes families whose incomes are less than
     200 percent of the federal poverty level.  Approximately 85
     percent of health center patients are at this income level or
     below.  In 1997, 1.2 million children under age 5 received care
     at health centers.  Four of every 10 patients seen at these
     health centers in 1997 were uninsured, and more than 3 of every
     10 were covered by Medicaid.  HRSA provided estimates that
     health centers served around 14 percent of the nation's
     uninsured children in 1995. 

Other federal programs help address childhood lead poisoning, but the
extent of their contribution is generally unknown.  HHS' Maternal and
Child Health Block Grant may fund lead poisoning prevention
activities in some states that have identified lead poisoning as a
critical health concern.  Head Start, another program that HHS
administers, also may fund lead screenings.  Head Start's primary
goal is to improve the social competence of children in low-income
families.  To support this goal, Head Start delivers a wide range of
services to disadvantaged young children, serving about 782,000
children in program year 1996-97.  These services include medical and
nutrition services such as lead screening. 

The Department of Agriculture's (USDA) Special Supplemental Nutrition
Program for Women, Infants, and Children (WIC) has also been involved
in lead screening for children.  WIC was established to counteract
the negative effects of poverty on prenatal and pediatric health and
combines direct nutritional supplementation, nutrition education and
counseling, and increased access to health care and social service
providers for pregnant, breastfeeding, and postpartum women and their
infants and children up to 5 years of age.  While the cornerstone of
WIC's mission is to provide nutrition services, WIC agencies are also
charged with assisting WIC participants to obtain and use preventive
health care services.  By providing on-site health services or
referring to other agencies, WIC links participants to appropriate
health-care providers.  Such services may include lead screening. 

HUD also administers a grant program to identify and control
lead-based paint hazards in low-income privately owned housing.  From
1992 to 1995, HUD awarded $280 million to state and local governments
for this purpose.  In fiscal year 1996, it awarded an additional $55
million to 20 grantees.  The Environmental Protection Agency (EPA)
regulates work practice standards for lead hazard evaluation and
control, develops training courses, sets minimum requirements for
contractor training and qualification, makes grants to states and
approves state programs for certifying lead contractors and
accrediting trainers, and defines hazardous levels of lead in dust,
paint, and bare soil.  EPA's grant program had awarded $36 million to
46 states, the District of Columbia, and 27 Native American tribal
nations as of February 1997. 


--------------------
\8 EPSDT is a comprehensive prevention and treatment program for
Medicaid recipients under 21 years of age. 

\9 The State Children's Health Insurance Program, established under
the Balanced Budget Act of 1997 to address the problem of uninsured
children, will provide another means of federal support for childhood
lead poisoning prevention.  States can expand their current Medicaid
program, establish a new program, or implement a combination of the
two approaches. 

\10 The Health Center Program, authorized under section 330 of the
Public Health Service Act, was formerly four separate programs: 
community health centers, migrant health centers, homeless health
centers, and centers for residents of public housing.  Before the
Health Center Consolidation Act of 1996 (P.L.  104-299, Oct.  11,
1996) these programs were authorized under sections 329, 330, 340,
and 340A of the Public Health Service Act. 


   OBJECTIVES, SCOPE, AND
   METHODOLOGY
---------------------------------------------------------- Chapter 1:5

The ranking minority member of the House Committee on Government
Reform and Oversight asked us to address

1.  the risk of lead poisoning faced by young children served by
federal health care programs,

2.  the extent to which children in these programs have been screened
for this condition,

3.  key reasons why screenings may not be occurring, and

4.  problems that federal health care programs face in ensuring that
children who have been determined to have harmful lead levels in
their blood receive timely follow-up treatment and other services. 

To address these objectives, we reviewed relevant legislation,
studies, and policy documents and interviewed officials from (1) CDC,
HCFA, HRSA's Bureaus of Primary Health Care and Maternal and Child
Health, and HHS' Administration of Children and Families; (2) USDA,
HUD, EPA, the Agency for Toxic Substances and Disease Registry, and
the Association of State and Territorial Health Officials; (3) health
centers receiving federal grant funds; (4) state and local lead
poisoning prevention programs; (5) the National Lead Information
Center, the Alliance to End Childhood Lead Poisoning, and other
experts in lead poisoning prevention; (6) the American Academy of
Pediatrics and other health care providers; and (7) programs the
director of the National Lead Information Center cited as models for
treating children for lead exposure--Montefiore Medical Center in the
Bronx, New York, the Children's Hospital in Boston, Massachusetts,
and the Kennedy Krieger Institute in Baltimore, Maryland. 

To assess the degree of harmful lead levels among young children in
federal health care programs as well as the extent to which these
children have been screened for lead poisoning, we analyzed data from
CDC's most recently released NHANES.\11 This survey contains
nationally representative information on the health and nutrition of
the U.S.  population gathered through direct physical examinations
and interviews.  Our February 1998 report and May 1998 letter to the
ranking minority member of the House Committee on Government Reform
and Oversight contained the initial results of our analysis of the
NHANES related to the Medicaid population.\12 The results pertaining
to the objectives in this comprehensive review are incorporated in
this report.  Appendix I explains in further detail our methodology
for analyzing the NHANES data. 

To determine the percentage of children covered by Medicaid who
received a blood lead test in selected states, we analyzed data in
HCFA's State Medicaid Research File for 15 states.  Appendix II
explains in further detail our methodology for analyzing the Medicaid
billing data.  To assess state Medicaid policies and procedures, we
sent a questionnaire to the director of the Medicaid program in all
50 states and the District of Columbia.  We received a 100-percent
response rate from Medicaid directors reporting on (1) program
coverage of services for children who have elevated blood lead
levels, (2) the availability of data on the prevalence of elevated
blood lead levels in the Medicaid population, (3) Medicaid or other
state monitoring of lead screening services, and (4) Medicaid or
other state monitoring of treatment for elevated lead levels.  The
respondents also provided copies of their state Medicaid policies and
any formal agreements they had with health departments, housing
departments, or others for ensuring that lead screening and treatment
services were provided to children enrolled in Medicaid.  Appendix
III explains in further detail our survey methodology. 

Although we interviewed HHS officials who administer the Maternal and
Child Health Block Grant program and the Head Start program, our work
with these programs was limited.  While they can support childhood
lead poisoning prevention activities, national data on how much lead
screening is conducted through the block grants or Head Start are not
available.  Many of the children served by these programs are also
served by the programs we did review--that is, they are served by the
CDC grant programs, are covered by Medicaid, or live in areas served
by health centers receiving federal grants.  Because our focus was on
federal activities to screen and treat children for elevated blood
lead levels, we did not assess the HUD and EPA lead programs.  We
previously reported on issues concerning HUD and EPA programs related
to lead poisoning prevention.\13

Appendix IV contains further details on federal screening and
treatment policies. 

We also visited seven federally supported health centers in Atlanta,
Georgia; Everett, Washington; New Bedford, Massachusetts; Brooklyn,
New York; Philadelphia, Pennsylvania; San Antonio, Texas; and
Watsonville, California, for the purpose of reviewing two samples of
medical records at each health center.  We assessed (1) the screening
of 1- and 2-year-old children visiting the center in 1996 and (2) the
follow-up of children identified with elevated blood lead levels in
1996.  We selected the health centers for a mix of geographic areas
and to target areas where children had a higher risk for lead
exposure, based on the number of children covered by Medicaid seen at
the health centers in 1996 and the number of houses built before 1950
in the centers' zip codes.  See appendixes V and VI for more details
about our methodology for the medical record review at the health
centers. 

We met with officials from six state and city childhood lead
poisoning prevention and surveillance programs that received CDC
grant funding.  These programs, generally located near the health
centers we visited, included programs run by the states of
California, Massachusetts, Texas, and Washington as well as New York
City and Philadelphia.  At each program, we discussed their
activities and assessed the extent to which they were tracking
children who had higher blood lead levels (20 g/dl or
higher) who were in our record reviews at the health centers we
visited.  Where applicable, we also discussed follow-up treatment
activities with local health departments.  We also discussed factors
that aided or impeded these follow-up activities.  Finally, we
obtained copies of relevant legislation and regulations in effect at
the time of each visit (conducted between late 1997 and early 1998). 
Appendix VII contains further details about our methodology and
summarizes information obtained on state and local requirements. 

We carried out our review from June 1997 through December 1998 in
accordance with generally accepted government auditing standards. 


--------------------
\11 The NHANES has been conducted periodically since 1960.  This
analysis is from Phase 2 (1991-94) of NHANES III, HHS,CDC, National
Center for Health Statistics, National Health and Nutrition
Examination III, 1988-94, NCHS CD-ROM, Series 11, No.  1A, ASCII
Version, July 1997. 

\12 Medicaid:  Elevated Blood Lead Levels in Children
(GAO/HEHS-98-78, Feb.  1998) and Children's Health:  Elevated Blood
Lead Levels in Medicaid and Hispanic Children (GAO/HEHS-98-169R, May
1998). 

\13 See Lead-Based Paint Hazards:  Abatement Standards Are Needed to
Ensure Availability of Insurance (GAO/RCED-94-231, July 15, 1994),
Lead-Based Paint Poisoning:  Children in Section 8 Tenant-Based
Housing Not Adequately Protected From Lead Poisoning (GAO/RCED
94-137, May 13, 1994), Toxic Substances:  Status of EPA's Efforts to
Develop Lead Hazard Standards (GAO/RCED-94-114, May 16, 1994),
Lead-Based Paint Poisoning:  Children Not Fully Protected When
Federal Agencies Sell Homes to Public (GAO/RCED-93-38, Apr.  15,
1993), Lead-Based Paint Poisoning:  Children in Public Housing Are
Not Adequately Protected (GAO/RCED-93-138, Sept.  17, 1993), and
Toxic Substances:  Federal Programs Do Not Fully Address Some Lead
Exposure Issues (GAO/RCED-92-186, May 15, 1992). 


ELEVATED BLOOD LEAD LEVELS REMAIN
A SIGNIFICANT PROBLEM FOR CHILDREN
SERVED BY FEDERAL HEALTH CARE
PROGRAMS
============================================================ Chapter 2

Our analysis of CDC survey data shows that elevated blood lead levels
remain a significant problem for children who are served by federal
health care programs.  The children participating in CDC's nationally
representative survey who were enrolled in or targeted by federal
health care programs were much more likely than other children to
have elevated blood lead levels.  Three-fourths of the children in
the survey found to have elevated blood lead levels were enrolled in
Medicaid or WIC or were targeted by HRSA's Health Center Program.\14

Data CDC gathered in its NHANES survey provided the basis for its
estimate that elevated blood lead levels are found in about 890,000,
or 4.4 percent, of U.S.  children aged 1 through 5.\15 Most recently
conducted during 1991-94, the NHANES gives comprehensive physical
examinations and in-depth interviews to a nationally representative
sample of the population (including almost 2,400 children aged 1
through 5 in the most recent survey).  A blood lead test is included
in the physical examination.  Demographic, health insurance, income,
and other information is also gathered in the interviews and
incorporated into the CDC database. 

Survey results showed that children who had elevated blood lead
levels were likely to be receiving health care benefits or services
through federal programs.  Children who were enrolled in or targeted
by federal health care programs constituted about 40 percent of all
1- through 5-year-olds in the sample but more than 77 percent of the
1- through 5-year-olds who had elevated blood lead levels. 
Projecting the sample results to the population at large, we estimate
that 688,000 of the estimated 890,000 children who have elevated
blood lead levels nationwide are enrolled in Medicaid or WIC or are
within the target population served by the Health Center Program.\16

The prevalence of elevated blood lead levels for the surveyed
children enrolled in Medicaid or WIC or living in low-income and
uninsured families targeted by the Health Center Program was about
8.4 percent--that is, 8.4 percent of these children had elevated
blood lead levels.  This rate was nearly five times the 1.7-percent
prevalence found among the children not enrolled in or targeted by
these federal health care programs. 

The program-by-program results together with projections of how many
children in each program have elevated blood lead levels are
presented below.  Because some children are eligible for more than
one program, the estimates total more than 688,000. 


--------------------
\14 While WIC is generally considered a nutrition program, for our
purposes we refer to it as one of the health care programs that we
reviewed. 

\15 Centers for Disease Control and Prevention, "Updated:  Blood Lead
Levels--United States, 1991-1994," Morbidity and Mortality Weekly
Report, Vol.  46, No.  7 (1997), pp.  141-46, and Morbidity and
Mortality Weekly Report, Vol.  46, No.  26 (1997), p.  607. 

\16 The remaining children who had elevated blood lead levels were
living in families whose incomes were more than 130 percent of the
poverty level, had some form of health insurance besides Medicaid,
and were not receiving WIC benefits. 


   RESULTS FOR SURVEYED CHILDREN
   ENROLLED IN MEDICAID
---------------------------------------------------------- Chapter 2:1

Our analysis of the NHANES data shows that about 1 in every 12, or
8.5 percent, of the 1-through 5-year-olds who were enrolled in
Medicaid had an elevated blood lead level.  Of particular note,
NHANES data indicated that Medicaid children constitute the majority
of children who have elevated blood lead levels high enough to
warrant clinical management, including evaluations for complications
of lead poisoning, environmental investigations, and other services. 
The NHANES data show that at least 83 percent of children aged 1
through 5 who had higher levels of lead toxicity (20 g/dl or
more) were enrolled in Medicaid.  Projecting the NHANES results for
the surveyed children in Medicaid to the national level, we estimate
that 535,000 of the 890,000 children who have elevated blood levels
are in families that have Medicaid health care coverage.\17


--------------------
\17 We previously reported this portion of our analysis in
GAO/HEHS-98-78.  In another analysis in which we looked at prevalence
and screening for Medicaid children aged 1 and 2, we found that
nearly 10 percent of children in Medicaid aged 1 through 2 had
elevated levels of lead in their blood.  See GAO/HEHS-98-169R. 


   RESULTS FOR SURVEYED CHILDREN
   IN WIC
---------------------------------------------------------- Chapter 2:2

Children at nutritional risk--those targeted by the WIC program--are
especially susceptible to lead poisoning.\18 For example, iron
deficiency has been shown to increase the toxicity of lead.  Our
analysis of NHANES data for children in families receiving WIC
benefits found that 1 in 9, or 12 percent, of these children had an
elevated blood lead level.  This rate translates to an estimate that
452,000 of the 890,000 children who have elevated blood lead levels
are members of families receiving WIC benefits, including 319,000
children who are also covered by Medicaid. 


--------------------
\18 See National Research Council, Measuring Lead Exposure in
Infants, Children, and other Sensitive Populations (Washington, D.C.: 
1993). 


   RESULTS FOR SURVEYED CHILDREN
   WITHIN THE HEALTH CENTER TARGET
   POPULATION
---------------------------------------------------------- Chapter 2:3

Although children receiving Medicaid benefits may receive their care
at federally supported health centers, these centers target those
with the greatest risk of going without medical care--often children
in families whose income is low and who also lack health
insurance.\19 Within this group, our analysis of NHANES data shows
that about 1 of every 16 children, or 6 percent, had an elevated
blood lead level.  Projecting this rate to the entire population, an
estimated 67,000 of the 890,000 children who have elevated blood
levels are in low-income and uninsured families and thus within the
target population for the Health Center Program. 


--------------------
\19 We defined "low-income family" as one whose income was less than
or equal to 130 percent of the federally defined poverty level at the
time of the NHANES survey.  We used this level because CDC in earlier
NHANES analyses defined incomes lower than this level as low-income. 
(See Morbidity and Mortality Weekly Report, Vol.  46, No.  7 (1997),
p.  141.)


MOST CHILDREN SERVED BY FEDERAL
HEALTH CARE PROGRAMS ARE NOT BEING
SCREENED FOR ELEVATED BLOOD LEAD
LEVELS
============================================================ Chapter 3

Despite federal policies to ensure that children in federal health
care programs are screened for elevated blood lead levels, most
children are not being screened.  Our analysis of NHANES data shows
that only 18 percent of all surveyed children enrolled in or targeted
by federal health care programs had been screened before
participating in the survey.  This means that most of the children
who are likely to have elevated blood lead levels--more than
400,000--have not been identified as having this condition.  Our
analysis of 15 states' Medicaid billing data similarly indicates that
overall screening is low, and information from the health centers we
visited shows that screening varies greatly from state to state and
location to location. 


   FEDERAL POLICIES ARE DESIGNED
   TO ENSURE THAT CHILDREN ARE
   SCREENED
---------------------------------------------------------- Chapter 3:1

CDC, HCFA, HRSA, and USDA have issued guidelines and requirements
regarding the extent to which children in federal health care
programs should be screened for elevated blood lead levels.  CDC's
general guidelines have recently changed:  Guidelines issued in
October 1991 called for virtually all children aged 1 through 5 to be
screened, but CDC's November 1997 guidelines recommended that state
health officials develop statewide plans for childhood lead screening
and better target children who are at specific risk.  Citing the
declining trend in average blood lead levels and generally low
screening rates, CDC revised its guidelines to both relax universal
screening recommendations in low-risk areas and increase the
identification of children in high-risk communities and populations. 
However, CDC maintains that, in general, children who receive
Medicaid or other federal health benefits should be screened unless
reliable, representative blood lead level data demonstrate the
absence of lead exposure.\20

HCFA and HRSA have required that Medicaid providers and health
centers receiving federal grants provide lead screening services. 
Federal Medicaid policy for lead screening was established by the
Omnibus Budget Reconciliation Act of 1989, which required that
Medicaid EPSDT services include blood lead level laboratory tests
appropriate for age and risk factors.  HCFA's Medicaid manual has
specifically required since 1992 that, in line with CDC's
recommendations, children enrolled in Medicaid be screened for
elevated blood lead levels at a minimum at ages 12 and 24 months, and
through 72 months if previously unscreened.  HRSA policy was
established in 1992 when Public Law 102-531 amended the Public Health
Service Act to include lead screening among the primary services that
health centers provide.  HRSA policy calls for health centers to
establish lead screening protocols that are consistent with CDC's
guidelines, including risk assessments at well child visits and an
initial blood lead test at at least 12 months.\21 Details of these
federal lead screening policies appear in appendix IV. 

USDA does not require that WIC programs screen participating
children.  Instead, WIC programs are encouraged to ask during
nutrition screening whether children have had a blood lead test and,
if not, to refer them to a lead screening provider.\22 Such
preventive health services might be financed by other federal
programs such as Medicaid, because many WIC recipients are also
eligible for Medicaid.  However, research has shown that WIC is the
single largest point of access to health-related services for
low-income preschool children.\23


--------------------
\20 CDC, Screening Young Children for Lead Poisoning:  Guidance for
State and Local Public Health Officials (Atlanta:  Nov.  1997). 

\21 Specifically, HRSA policy indicates that each well-child visit
and other pediatric visits as appropriate from age 6 months to 6
years should assess risk of exposure to lead.  High- risk children
should receive an initial blood lead test at age 6 months or when
they are determined to be at high risk.  Low-risk children should
receive an initial blood lead test at age 12 months. 

\22 Elevated blood lead levels may make children eligible for WIC if
other qualifying criteria are met.  In June 1998, when USDA set
national eligibility standards for its WIC program, it included an
elevated blood lead level as a qualifying condition for nutritional
risk.  In earlier years, WIC had a more significant role in lead
screening, as discussed later in this report. 

\23 According to researchers, approximately 5 to 7 million infants
and children younger than 5 years old participated in WIC monthly
during 1997.  WIC participants generally visit clinics every 2 to 3
months to receive nutrition services and food vouchers, and more
comprehensive health status evaluations are conducted every 6 to 12
months during certification visits.  See Abigail Shefer and Jim Mize,
"Primary Care Providers and WIC:  Improving Immunization Coverage
Among High-Risk Children," Pediatric Annals, Vol.  27, No.  7 (1998),
pp.  428-33. 


   NATIONAL SURVEY DATA SHOW THAT
   ONLY ONE IN FIVE CHILDREN HAS
   BEEN SCREENED
---------------------------------------------------------- Chapter 3:2

Despite federal policies to ensure that children in federal health
care programs receive screening services, our analysis of NHANES and
Medicaid data indicates that only about 18 percent have been
screened.  The NHANES database can be used to estimate lead screening
for both the population as a whole and various groups such as those
eligible for federal health care program benefits because it contains
responses from participating parents, guardians, and others as to
whether the children have been screened for lead.  Screening rates
for children aged 1 through 5 in or targeted by the three federal
health care programs ranged from 17 to 19 percent, compared with 7
percent for children not in any of these programs (see table 3.1). 



                               Table 3.1
                
                   Estimated Lead Screening Rates for
                       Children Aged 1 Through 5

                                                                Percen
                                                                     t
                                                                screen
                                                                    ed
--------------------------------------------------------------  ------
All children aged 1-5                                               11
Children enrolled in Medicaid\a                                     19
Low-income and uninsured children\b                                 17
Children enrolled in WIC\c                                          18
Children not covered by Medicaid or WIC and not low-income and       7
 uninsured
----------------------------------------------------------------------
\a Our previous analysis of lead screening for Medicaid children aged
1 through 2 showed a screening rate of 21 percent.  See Children's
Health:  Elevated Blood Lead Levels in Medicaid and Hispanic Children
(GAO/HEHS-98-169R, May 18, 1998). 

\b This population of children is within the target population for
the Health Center Program. 

\c Children participating in WIC may also be participating in the
Medicaid program or may have low incomes and no health insurance. 
These figures are for ages 1 through 4, since WIC is for children
through age 4 only. 

Since the NHANES analysis on lead screening is based on parents' and
guardians' reports of whether participating children have been
screened, it is subject to the accuracy of their awareness and
recall.  However, it is supported by other data reflecting screening
rates for certain children enrolled in Medicaid.  We analyzed data
from HCFA's State Medicaid Research File to assess the extent to
which individual state Medicaid programs had been billed for lead
tests for children receiving Medicaid coverage for a year or more.\24
This analysis of 1994 and 1995 data from 15 state Medicaid
fee-for-service programs showed a screening rate similar to that of
the NHANES data.  On average, state Medicaid programs provided lead
tests for 21 percent of 1- and 2-year-old children covered for a full
year by Medicaid.  While these billing data provide information only
for children covered by Medicaid fee-for-service (rather than managed
care) arrangements, data reported to us by state Medicaid agencies
were the basis for our estimate that as of June 1997, about 60
percent of Medicaid-enrolled children had fee-for-service
arrangements.\25 National data on lead screening within Medicaid
managed care programs were not available. 


--------------------
\24 HCFA's State Medicaid Resource File contains Medicaid
fee-for-service information on eligibility, billing claims, and
utilization for states that participate in the Medicaid Statistical
Information System.  Billing data are limited to the extent that they
do not provide information on provided services for which no
reimbursement was sought.  For this reason, we excluded from our
analysis (1) children receiving Medicaid for less than 1 year, (2)
children with any indication of having other insurance coverage, and
(3) any data for states that indicated to us that their public health
laboratory performed blood lead tests at no fee to the Medicaid
program.  Further details on our use of state Medicaid data appear in
appendix II. 

\25 HCFA does not maintain complete screening data on children
enrolled in Medicaid who are under age 6 and have managed care
arrangements.  Since the number of people with managed care
arrangements has been increasing, the proportion of Medicaid children
with fee-for-service arrangements in the earlier years of our
analysis (1994 and 1995) is likely to have been higher. 


   INSUFFICIENT SCREENING MEANS
   MANY CHILDREN REMAIN
   UNDIAGNOSED
---------------------------------------------------------- Chapter 3:3

Given these screening levels, many children who have elevated blood
lead levels are not likely to have been so identified and therefore
have not been treated.  The lead screening histories in the NHANES
allow us to estimate the number of these undiagnosed cases.  That is,
the survey data show whether children had been screened for lead
before participating in the survey and whether they had elevated
blood lead levels (as identified through NHANES blood lead tests). 
In particular, about two-thirds of participating children who had
elevated blood lead levels and were enrolled in or targeted by
federal health care programs had not received a blood lead test
before the survey.  Thus, we estimate that about 436,000 of the
688,000 children who have elevated blood lead levels and are enrolled
in or targeted by federal health care programs have not been
diagnosed as having this condition.  Our estimates, based on the
results for children aged 1 through 5, are shown in figure 3.1. 

   Figure 3.1:  Estimated Number
   of Children Aged 1 Through 5
   Years Who Have Undetected
   Elevated Blood Lead Levels by
   Federal Health Care Assistance
   Category

   (See figure in printed
   edition.)


   SCREENING RATES VARY BY
   LOCATION
---------------------------------------------------------- Chapter 3:4

Information from the Medicaid billing database we analyzed for 15
states and our review of seven health centers indicate that the
extent to which children are screened for elevated blood lead levels
varies widely from location to location.  State Medicaid agency
screening rates in fee-for-service arrangements ranged from less than
1 percent of children aged 1 through 2 in Washington to about 46
percent in Alabama.\26 Figure 3.2 provides the results of this
analysis by state. 

   Figure 3.2:  State Medicaid
   Billing Rates for Blood Lead
   Laboratory Tests for Children
   Aged 1 and 2 in 1994 and 1995

   (See figure in printed
   edition.)

Most of the seven health centers we reviewed were screening at rates
much higher than the overall rates we found in the NHANES and
Medicaid data.  However, as with state Medicaid programs, screening
varied widely between the seven centers.  Within 7 of 10 HHS regions,
we selected centers that could be considered to be in high-risk areas
on the basis of (1) the number of pre-1950 homes and (2) the number
of children aged 4 and younger in Medicaid and served by the health
centers in 1996.\27 We assessed the screening of 1- and 2-year-olds
because Medicaid and HRSA require at least one screening for these
children.  Three centers--Brooklyn, New York, New Bedford,
Massachusetts, and Philadelphia--screened nearly all the children
whose files we reviewed.  In contrast, the center in Everett,
Washington, apparently screened none.\28 Table 3.2 contains screening
rates we identified for each center, and appendix V contains a
further discussion of our methodology and findings. 



                               Table 3.2
                
                 Lead Screening of 1-and 2-Year-Olds in
                      1996 at Seven Health Centers

                                                                Percen
                                                                  t of
                                                                childr
                                                                    en
                                                                  ever
                                                                screen
Health center site                                                ed\a
--------------------------------------------------------------  ------
Atlanta, Ga.                                                        64
Everett, Wash.                                                       0
New Bedford, Mass.                                                 100
Brooklyn, N.Y.                                                      93
Philadelphia, Pa.                                                  100
San Antonio, Tex.                                                   50
Watsonville, Calif.                                                 80
----------------------------------------------------------------------
\a Based on a random sample of files for children born between
January 1, 1994, and June 30, 1995, and seen at the health center
during 1996. 

State and local decisions seem to be the major factor in determining
the extent to which children in federal health care programs are
screened, as discussed in the next chapter. 


--------------------
\26 We contacted Washington and Alabama health departments to
determine whether these rates were consistent with data on lead
screening they collected.  Both confirmed that these screening rates
were consistent with those reported in their states.  For example, in
1996, less than 1 percent of all children in Washington had been
screened for lead poisoning. 

\27 We used this age group because HRSA requires health centers to
report for it.  See app.  V for a more detailed discussion of our
methodology and findings at health centers. 

\28 Officials in Everett told us that they had performed only three
lead tests in 1997 and could not identify screenings for 1996, the
year we reviewed.  Officials at the Washington State Department of
Health, where the state's registry of lead tests is maintained,
confirmed that this center reported conducting only three tests in
1993-98.  As a result, we did not specifically review medical records
to determine the center's screening rate. 


SCREENING RATES ARE AFFECTED BY
LACK OF OVERSIGHT AND OTHER
PROBLEMS
============================================================ Chapter 4

Lead screening rates in federal health care programs are low for
several reasons.  One is that federal and state agencies often do not
monitor or otherwise ensure the implementation of federal screening
policies.  This is reflected in the many locations where we found
screening policies less stringent than federal policies.  A second
and related reason is that the perception of the problem's
seriousness varies greatly from place to place, directly affecting
the screening policies that are adopted.  Third, screening efforts
are hampered by difficulties in providing preventive health care
services to children in these programs.  For example, health
officials said that a significant problem is that some families do
not seek preventive care services such as lead screening, instead
visiting health care providers only when children are sick. 

Screening rates can be increased in several potential ways.  One is
to ensure that perceptions about the extent of the problem are backed
up with reliable data.  Most state Medicaid programs and health
departments we contacted lacked data to determine the extent to which
elevated blood lead levels are a problem in their communities.  A
second way is to improve the coordination between lead screening and
other preventive care activities.  For example, HHS' experience with
improving immunization rates among children who qualify for federal
programs might provide models and avenues for use in lead screening. 
The shift to managed care within state Medicaid programs might also
create additional opportunities for improving lead screening,
although recent research is showing that many state Medicaid agencies
have yet to include lead screening responsibilities in their
contracts with managed care organizations. 


   FEDERAL OVERSIGHT HAS NOT
   ENSURED THAT SCREENING POLICIES
   ARE FULLY IMPLEMENTED
---------------------------------------------------------- Chapter 4:1

We found that relatively little activity monitors or otherwise
ensures the implementation of federal screening requirements, either
for Medicaid or for the Health Center Program.  HCFA does not review
state Medicaid programs for compliance with EPSDT lead screening
policies, and nearly half the state Medicaid programs have adopted
screening policies that are less rigorous than the federal policies. 
Further, many state Medicaid programs conduct little or no monitoring
to determine whether children are being screened.  While HRSA reviews
health centers, it has not identified the problems we found with
health centers not following federal screening policies.  However,
screening rates are highest where the states have their own statutes
or regulations with specific screening requirements and other ways of
ensuring compliance. 


      LACK OF HCFA OVERSIGHT MEANS
      STATE MEDICAID SCREENING
      POLICIES ARE OFTEN LESS
      RIGOROUS THAN HCFA'S
-------------------------------------------------------- Chapter 4:1.1

HCFA does not monitor state Medicaid agencies' implementation of lead
screening policies.  A HCFA official told us that the agency assumes
that the states are providing EPSDT services as specified in HCFA
policy and does not specifically review them for comparability with
federal policies.  HCFA does set and monitor performance standards
regarding certain EPSDT services such as preventive vision, dental,
and hearing screening.  These standards do not include lead
screening. 

Many state Medicaid programs do not match HCFA's policy that lead
screening services be provided to children at 12 and 24 months of
age, and through 72 months if previously unscreened.\29 Specifically,
we found that 24 of the 51 states have policies that are less
rigorous than HCFA's.\30 For example, 2 states require screening only
once, at either 12 or 24 months, and 7 do not require minimum
screening tests. 

Many state policies do not follow HCFA's policy of screening children
aged 36 months through 72 months if previously unscreened, which
could leave many children with undetected and untreated elevated
blood levels.  Specifically, 21 states do not require screening for
children aged 3 through 5 who have not been previously screened.  An
analysis of NHANES data shows that about 41 percent of all children
in Medicaid who have undetected elevated blood lead levels are in
this age group.  Projected to the entire population, this represents
146,000 children who have elevated blood lead levels, are in
Medicaid, are aged 3 through 5, and have not been screened.  To the
extent that they reside in the 21 states that have no screening
requirement, these 3- through 5-year-olds are likely to have their
conditions go undetected. 

HCFA has recently amended its policy and in so doing has clarified an
ambiguity that may have contributed to the variety of screening
policies we found.  Until recently, HCFA's Medicaid manual contained
potentially conflicting guidance regarding blood screening tests.  It
stated that blood lead screening was required for all children at
least at 12 and 24 months of age, but it also stated that physicians
should use their medical judgment in determining the applicability of
the laboratory tests.  The manual indicated that laboratory tests
(including that for lead toxicity) should be conducted "as
appropriate." In September 1998, HCFA changed the manual to read,
"With the exception of lead toxicity screening, physicians providing
screening services under the EPSDT program use their medical judgment
in determining the applicability of the laboratory tests or analyses
to be performed.  Lead toxicity screening must be provided."\31


--------------------
\29 HCFA's 1993 state Medicaid manual indicated that a child between
the ages of 24 months and 72 months who had not been screened for
blood lead must be screened immediately.  HCFA's 1998 Medicaid manual
change indicated that children between the ages of 36 months and 72
months must receive a screening blood lead test if they have not been
previously screened for lead poisoning. 

\30 The District of Columbia is counted as a state. 

\31 HCFA, State Medicaid Manual, Part 5--Early and Periodic
Screening, Diagnosis, and Treatment (EPSDT), Transmittal No.  12,
Washington, D.C., Sept.  1998. 


      STATE MEDICAID OVERSIGHT IS
      OFTEN LACKING
-------------------------------------------------------- Chapter 4:1.2

Many state Medicaid agencies are not monitoring Medicaid providers'
lead screening activities.  We surveyed all 51 state Medicaid
agencies to see whether and how they, the health department, or
others monitor fee-for-service and managed care providers to ensure
that children in Medicaid were screened.\32 Thirty states indicated
that they monitor either fee-for-service providers or managed care
providers to some degree.  Twenty-two of 47 states with children in
fee-for-service care provide some degree of monitoring; 26 of 41
states with children in managed care do so (see table 4.1).  Most do
so by auditing a sample of medical records. 



                         Table 4.1
          
             State Lead Screening Monitoring of
                    Children in Medicaid

                               Type of monitoring\a
                        ----------------------------------
                States
                  that
               monitor
                  lead
             screening
                   for
              children   Reporting   Audits of   Review of
                    in  requiremen     medical     billing
              Medicaid          ts     records        data
----------  ----------  ----------  ----------  ----------
Fee-for-            22           4          16           6
 service
 providers
 \b
Managed             26          10          22           7
 care
 providers
 \c
----------------------------------------------------------
\a Numbers do not add because some states have more than one
monitoring activity. 

\b Forty-seven state Medicaid programs reported having some children
in fee-for-service arrangements in 1997. 

\c Forty-one state Medicaid programs reported having some children in
managed care arrangements in 1997. 


--------------------
\32 In the survey, we specifically asked for activities that monitor
capitated or prepaid providers.  For clarity, we refer to these
providers as "managed care" providers. 


      HRSA REVIEWS HAVE NOT
      IDENTIFIED HEALTH CENTERS'
      LACK OF ADHERENCE TO FEDERAL
      POLICIES
-------------------------------------------------------- Chapter 4:1.3

Health centers are expected to follow not only HCFA's screening
policy as set out in the Medicaid manual but also HRSA's screening
policy.  HCFA requires screening for children 12 and 24 months old,
while HRSA requires screening only at 12 months.  HCFA's requirements
cover only children in Medicaid, while HRSA's cover all children seen
at the health centers, although these often include children in
Medicaid.\33 Officials at one of the seven health centers we visited
advised us that the center had screened virtually no children for
lead poisoning and, thus, the center was not following either HCFA's
or HRSA's policy of screening children at least once.  At two other
health centers, only one of the two policies was being followed: 

  -- The Watsonville health center medical director told us that the
     center was relying on screening children at 12 months.  While
     this paralleled HRSA policy, it was not consistent with the
     Medicaid policy requiring that screening services be provided to
     children at both 12 and 24 months. 

  -- Officials at the San Antonio health center stated that they had
     a screening policy for children in Medicaid that was consistent
     with HCFA's.  It had no policy for screening uninsured or other
     children visiting the center, as is required by HRSA. 

Although HRSA monitors health centers' lead screening policies, it
has not identified the discrepancies we found.  HRSA conducts
periodic reviews at health centers, and these reviews are supposed to
assess whether the health center evaluates all children for lead
poisoning risk, participates in lead poisoning prevention programs,
and provides screening and testing services.  Reviewers are
instructed to look at medical records for the use of preventive
health schedules and strategies for lead screening but are not
required to assess actual lead screening practices or rates.  None of
the reviews for the centers we visited had reported the concerns with
the lead screening policies and practices we identified in our
review. 


--------------------
\33 In addition, health centers may provide health care for children
enrolled in Head Start.  Reviewing individual states' Head Start
policies for requiring lead screening was outside our scope, but we
did determine that federal Head Start policy differs from that of
HCFA and HRSA in that it allows Head Start programs to set lead
screening policies locally. 


      SCREENING RATES ARE HIGHEST
      IN STATES WITH SCREENING
      REQUIREMENTS
-------------------------------------------------------- Chapter 4:1.4

Among the states we reviewed, the rate at which children were
reportedly screened for blood lead levels was highest in states that
had their own screening requirements.  Such laws are relatively
infrequent:  According to CDC, among 20 states that CDC had surveyed,
only 3 (Illinois, New York, and Rhode Island) have laws or
administrative rules requiring screening.  Among the seven states and
localities we contacted, New York and Massachusetts had regulations
that providers screen for blood lead levels.  New York law requires
that all children be screened at least at or around ages 1 and 2, and
Massachusetts requires that at a minimum all children be screened
annually through the age of 48 months.  Both states also require
proof of lead screening as a condition for entering day care or
kindergarten.\34

The requirements and built-in enforcement mechanisms in the two
states' laws appeared to make a difference in screening:  Among the
states and localities we visited, New York City and Massachusetts
screened the highest proportion of children.  The New York City
Health Department reported that in 1996, 44 percent of 1- and
2-year-olds had been screened, and Massachusetts reported a
54-percent screening rate for children aged 1 through 5 for that
year, compared with generally lower screening rates estimated by
other programs we visited in states without screening laws.\35

These observations are consistent with those of a CDC-contracted
research study evaluating activities of CDC's Lead Poisoning
Prevention Branch.  One conclusion of the study was that the legal
infrastructure is important but underdeveloped.  Statutes and
ordinances in screening, reporting, and treatment activities were not
in place, or not enforced, in many surveyed sites.\36


--------------------
\34 Specifically, Massachusetts requires that for entry to
kindergarten children present evidence of having been screened for
lead poisoning.  New York requires child care providers, public and
private nursery schools, and preschools that are licensed, certified,
or approved by any state or local agency to obtain a copy of a
certificate of lead screening for every child who is at least 1 year
old but younger than 6. 

\35 While most of the programs we reviewed that were in places
without screening laws (Georgia, Texas, and Washington and
Philadelphia) did not know actual screening rates in the city or
state, most had estimated screening for selected time periods and
populations of children.  See appendix VII for a further discussion
of these estimates. 

\36 Macro International, Inc., Executive Summary:  Evaluation of
Activities of the Lead Poisoning Prevention Branch, Contract
200-88-0641-18, Mar.  30, 1994. 


   PERCEPTIONS OF THE PROBLEM'S
   SERIOUSNESS VARY GREATLY AND
   AFFECT DECISIONS TO SCREEN
---------------------------------------------------------- Chapter 4:2

The variation in screening rates that we found reflects the fact that
lead poisoning is perceived as a significant problem in some places
but not in others.  Several health center officials indicated that a
major barrier to screening is physicians' perceptions that lead
exposure is not a problem in their communities.  Supporting these
views, a 1996 Academy of Pediatrics survey of 734 primary care
pediatricians found that the most commonly reported reason the
surveyed pediatricians did not screen was a reported low prevalence
of elevated blood lead levels among their patients.  Furthermore,
only 38 percent of primary care pediatricians believed that the
benefits of screening exceeded the costs.\37

The survey also found that not all providers agree with CDC's
definition of the level of concern for lead toxicity.  Seventy-three
percent of pediatricians surveyed agreed that blood lead levels at or
higher than 10 g/dl should be considered elevated, but 16
percent disagreed.\38 Eighty-nine percent of primary care
pediatricians believed that epidemiologic studies should be performed
to determine which communities have high proportions of children who
have elevated blood lead levels.  The survey found that many
pediatricians may want additional guidance about when to consider
selective screening. 

Similarly, a 1996 study produced for the Childhood Lead Poisoning
Prevention Branch of the California Department of Health Services
assessed providers' blood lead screening practices and attitudes and
found that "Many physicians who care for children are not convinced
that lead poisoning is a significant health issue for their
patients."\39 The report concluded that physicians would be more
likely to screen if they thought that the cost-benefit ratio of
screening were more attractive.  Frequently identified barriers to
screening included a lack of solid local prevalence data, the absence
of a quality screening questionnaire to identify risk, parent and
physician resistance to venous blood draws, the absence of an
effective medical treatment for identified cases lower than 45
g/dl, and the lack of access to screening for some children
who are at greatest risk for lead poisoning.\40

The opinions of a state's medical establishment can have a profound
effect upon the state's efforts to screen its at-risk population. 
For example, the Massachusetts health department reported that 3.7
percent of the children who had been screened had elevated blood lead
levels, and the state has a policy of screening all children annually
until the age of 48 months.  In contrast, even though the Washington
lead registry shows that 3 percent of children screened for lead in
that state have elevated blood lead levels, providers there
apparently regard 3 percent as evidence that elevated blood lead
levels are not a major concern.  In discussions with health
department, Medicaid, and provider community officials, and in
reviewing provider commentaries on lead screening in Washington, we
learned that providers in the state often did not support testing for
blood lead levels because lead poisoning is not viewed as a
significant problem.  However, a survey in high-risk areas in
Washington found prevalences of blood lead levels greater than 10
g/dl as high as 8.4 percent. 

The influence of such views can be so strong that even children who
seem to be at obvious risk of lead exposure might not be screened. 
We visited the health center in Everett, Washington, because of its
location in a zip code with high numbers of pre-1950 houses and
because it served relatively high numbers of children in Medicaid. 
However, we also learned that it was a few blocks from a
state-designated Superfund site, a lead, gold, silver, and arsenic
smelter at the turn of the century.  Many soil samples taken in
residential neighborhoods within the boundaries of the site had
levels of lead contamination greater than the state-mandated cleanup
level, and one sample exceeded the state level by nearly 40 times. 
Despite the fact that the health center served children living within
the boundaries of this site, the medical director advised us that
virtually none of the children were screened for elevated blood lead
levels.\41 According to health center officials, the local health
department had for years discouraged providers at the health center
from screening for elevated blood lead levels because of the
perception that there was not a problem in the area.  However, we
were advised that in response to our review, the health department
provided the health center with guidance on screening children
visiting or playing near the smelter site for elevated blood lead
levels, as well as children living in older housing and with other
risk factors. 

To some extent, the legal infrastructure for lead screening and
related activities is influenced by the perceptions of physicians and
others about the extent to which lead exposure is a local problem. 
Although faced with the loss of federal grant money, some states have
not passed laws or otherwise demonstrated that they have the legal
authority and ability to support housing-related lead poisoning
prevention activities (addressing training, certification, and
accreditation programs for lead-based paint professionals such as
lead inspectors and abatement contractors).\42 While housing-related
lead poisoning prevention programs were outside the scope of our
review, since they do not directly address lead screening and medical
treatment activities, states' legislative experiences provide
insights about variations in the states' efforts and legal
infrastructure.  A 1998 report found that many states were unable to
pass legislation in part because of (1) mixed messages from federal
and state agencies and the medical community about the seriousness of
the public health risk from lead and (2) a lack of compelling data at
the state level to support legislation.\43

Perceptions of the problem affect not only physicians' decisions to
screen but also officials' views on monitoring the implementation of
federal lead screening policies.  For example, HRSA officials in
several regions responsible for health center performance reviews
(including lead screening and treatment) indicated to us that they
did not believe lead poisoning was a concern in their regions. 
According to a HCFA official, a 1994 survey of 967 Medicaid-eligible
children in Alaska has often been cited as evidence that federal
screening policies are unreasonable and should not be enforced.\44
This survey, finding that less than 1 percent of Medicaid-eligible
children had elevated blood lead levels, was the basis for a 1997
Council of State and Territorial Epidemiologists' position statement
that screening should be state-specific and that HCFA should allow
state (targeted screening) plans to include children enrolled in
Medicaid.\45


--------------------
\37 James Campbell and others, "Blood Lead Screening Practices Among
US Pediatricians," Pediatrics, Sept.  1996, pp.  372-77. 

\38 Another survey of 155 pediatricians found that only two-thirds
knew the lowest blood lead level associated with deficits in
cognition.  See Susan Ferguson and Tracy Lieu, "Blood Lead Testing by
Pediatricians:  Practice, Attitudes, and Demographics," American
Journal of Public Health, Vol.  87, No.  8 (Aug.  1997), pp. 
1349-51. 

\39 Duerr Evaluation Resources, Final Report:  Results of a Statewide
Study of Physician Attitudes, Knowledge and Practices Related to
Childhood Lead Poisoning (Chico, Calif.:  Department of Health
Services, Childhood Lead Poisoning Prevention Branch, Nov.  1996). 

\40 CDC supports the use of venipuncture (or venous) blood draws or a
process called "fingerstick" as the sample-collection method,
depending on the accuracy of the test results, the availability of
trained personnel, convenience, and cost.  In fingerstick sampling, a
small amount of blood is collected from a puncture in a child's
finger.  According to CDC, if children's fingers are cleaned
carefully, capillary (or fingerstick) sampling can perform well as a
screening tool. 

\41 The Agency for Toxic Substances and Disease Registry (ATSDR)
lists lead second in its ranking of dangerous contaminants.  A 1992
ATSDR analysis paper reviewed several quantitative studies on the
effect of lead-contaminated soil on children's blood lead levels and
found a strong positive correlation between exposure to
lead-contaminated soil and lead levels.  ATSDR recommended that, at
all sites, health assessors evaluate the need for follow-up
activities.  See Charles Xintaras, "Analysis Paper:  Impact of
Lead-Contaminated Soil on Public Health," HHS, Public Health Service,
ATSDR, Atlanta, Georgia, May 1992,
http://atsdrl.atsdr.cdc.gov:8080/cxlead.html#head011000000000000
(retrieved 2/10/98 12:17:40). 

\42 Under section 404 of the Toxic Substances Control Act as added by
the Housing and Community Development Act of 1992, states had until
August 31, 1998, to implement a federally authorized program to
administer lead poisoning prevention activities addressing training,
certification, and accreditation programs for lead-based paint
professions.  One condition of federal authorization was to
demonstrate that the state had the legal authority and ability to
implement the program.  Without an authorized program by August 31,
1998, states were subject to an EPA-administered and -enforced
program and concomitant loss of federal grant money for the preempted
state programs. 

\43 Analysis of Lead (Pb) Hazard Reduction Legislation:  Implications
for Washington State (Olympia, Wash.:  Washington State Department of
Health, Apr.  1998).  Other barriers cited included that the
legislative climate was not conducive to passing any new legislation
that might cost constituents money and concern about regulatory
reform and the lack of funding or unfunded mandates. 

\44 Laura Robin, Michael Beller, and John Middaugh, Childhood Lead
Screening in Alaska:  Results of a Survey of Blood Lead Levels Among
Medicaid-Eligible Children (Anchorage:  Alaska Dept.  of Health and
Social Services, Oct.  10, 1994). 

\45 Council of State and Territorial Epidemiologists, 1997 CSTE
Annual Meeting Position Statement EH-1 (Revision of Blood Lead
Screening) (Montgomery, Ala:  1997), http://www.cste.org/page61.html
(cited Oct.  29, 1997). 


   DIFFICULTIES IN PROVIDING
   PREVENTIVE CARE SERVICES KEEPS
   SCREENING RATES LOW
---------------------------------------------------------- Chapter 4:3

Even states that have mandatory lead screening laws are not screening
all children.  To some extent, low rates of screening reflect another
important factor:  Many children are not receiving preventive health
care in general through well-child visits.  Health center and health
department officials said that a significant barrier to higher
screening rates is that many children do not receive preventive
health care of any kind.  Health center officials told us that it is
difficult to convince parents of the importance of preventive care
when their children are not sick and, as a result, many children
visit their providers only when they are sick.  To illustrate, health
center officials at the center we visited in Texas told us that for
every well-child visit, they provide more than 80 acute care visits. 

Our studies and those conducted by others lend further support to the
views we heard expressed.  In a study examining the effects of health
care insurance on access to care, we found that although having
health insurance and a regular source of health care facilitates a
family's use of health services, low family income and education
levels, lack of transportation, and language differences are barriers
to obtaining and appropriately using them.\46 A 1997 HCFA-supported
study on the use of EPSDT and other preventive and curative services
by children enrolled in Medicaid also found particular challenges in
providing preventive health services.\47 Using 1992 Medicaid billing
data from four states, the study found that only 54 percent of the
children recommended for well-child visits (and, thus, preventive
care) actually made such visits. 

A related problem, health center officials said, is that in many
cases at-risk children are not screened because parents do not ensure
that their children receive the blood lead tests ordered by their
physicians.  Health officials and a California assessment of the
issue indicated that because many clinics and physicians' offices
prefer venous blood draws to obtain the blood sample and do not have
a readily available pediatric phlebotomist (or blood-drawer) to
conduct blood tests, children must be referred elsewhere for testing. 
Many of these children never arrive at the sometimes distant
facilities they are referred to and consequently are not tested.  The
California Lead Poisoning Prevention Program identified the reasons
the children do not receive tests as ordered as such things as
parents' lack of transportation or child care for children who would
remain at home, difficulty in getting time off from work, and a lack
of understanding of the test's importance.\48

A new medical device may make lead tests easier to administer and
perhaps reduce this problem.  Our review of medical records at the
health centers showed that typically physicians send blood samples to
laboratories for analysis and may not receive the results for several
days.  If the results show that a child has an elevated blood lead
level, another appointment must be scheduled to perform a
confirmatory test or other follow-up, which may not be kept.  In
September 1997, the Food and Drug Administration approved the first
hand-held screening device for testing blood lead levels.  While
providers must still obtain a blood sample through a fingerstick
procedure, the device shows the lead level results immediately
without the use of a laboratory.  Although the hand-held device makes
tests more convenient for providers, it complicates the gathering of
data by state and local health departments.  For the most part,
states rely upon data from laboratories to assess their screening and
prevalence rates.  If blood tests are not sent to laboratories but
instead are interpreted on the spot, states will need to identify an
alternative means, such as representative surveys, for obtaining this
information. 


--------------------
\46 Health Insurance:  Coverage Leads to Increased Health Care Access
for Children (GAO/HEHS-98-14, Nov.  1997). 

\47 Norma Gavin and others, Comparative Study of the Use of EPSDT and
Other Preventive and Curative Health Care Services by Children
Enrolled in Medicaid:  Final Project Synthesis Report (Research
Triangle Park, N.C.:  Research Triangle Institute, Apr.  1998.)

\48 To help address this barrier, the Childhood Lead Poisoning Branch
of the California Dept.  of Health Services has developed a program
to increase onsite blood lead testing by health care providers.  See
Guidance Manual for Implementing Fingerstick Sampling (Emeryville,
Calif.:  Childhood Lead Poisoning Prevention Branch, California
Department of Health Services, Sept.  1997). 


   BETTER DATA ON THE PREVALENCE
   OF ELEVATED BLOOD LEAD LEVELS
   AND BETTER PROGRAM COORDINATION
   COULD HELP IMPROVE SCREENING
---------------------------------------------------------- Chapter 4:4

Two types of actions could help resolve the problems that health
officials and others have identified.  First, because most state
Medicaid programs and health departments we contacted lack good data
to assess the risk of lead poisoning in local communities, improved
data collection might help them develop a better understanding of the
degree to which portions of their communities' populations are
significantly at risk.  This is particularly important because the
prevalence of elevated blood lead levels can vary even within a
region or community.  Second, further coordination between lead
poisoning programs and programs addressing other preventive health
care services could help identify models and avenues for identifying
and targeting the at-risk population for lead screening.  While the
growth of managed care represents another opportunity to improve lead
screening, recent research indicates that many states have yet to
address lead screening responsibilities in managed care contracts. 


      MOST MEDICAID PROGRAMS AND
      MANY STATE HEALTH
      DEPARTMENTS LACK THE DATA
      NEEDED TO ASSESS RISK AND
      DEVELOP TARGETED SCREENING
      RECOMMENDATIONS
-------------------------------------------------------- Chapter 4:4.1

Most state Medicaid programs and health departments we contacted lack
representative, reliable data from which to assess true prevalence
and, thus, risk.  According to CDC, the best data available for
developing state and local screening policies is actual
population-based data about the prevalence of elevated blood lead
levels--data that show the extent of elevated blood lead levels in
children who represent the entire population.  CDC guidelines state
that "These data should be used to explain and support the
recommendations to those who must carry them out, especially child
health-care providers, medical groups, managed-care organizations,
insurers, and parents."

Responses to our survey show that most Medicaid programs lack
prevalence information needed to best target screening and to
document the absence of lead exposure within their population of
children--specifically, data on the extent of screening and
prevalence of elevated blood lead levels.  In our survey of state
Medicaid programs, we asked directors whether their states had all
the information they needed to determine the extent of screening and
the prevalence of elevated blood lead levels in the Medicaid
population--including the number of children in Medicaid, the number
of children in Medicaid who are screened for elevated blood lead
levels, and the number of those who have been identified as having
elevated blood lead levels.  Directors in only 12 states responded
that they could readily produce such data.  Twenty-nine indicated
that getting such data would be difficult. 

Each of the seven CDC-supported lead poisoning prevention and
surveillance programs we contacted indicated that their states have
laws requiring laboratories or others to report certain results of
blood lead tests.  However, most of these laws are not comprehensive
enough to ensure that a state can identify the extent of childhood
blood lead screening and the true prevalence of elevated blood lead
levels in children by local area.  To do so, reporting all blood lead
levels, including those not considered to be elevated, would be
necessary, and a representative sample of children would have to be
screened.  Of the seven programs we reviewed, three were in states
that had such universal reporting laws:  Massachusetts, New York, and
Washington.  Only Massachusetts and New York had screened enough
children to ensure that their prevalence data represented the
population of children in the state.  California, Georgia,
Pennsylvania, and Texas required reporting of lead levels only if
they were above a defined threshold; for example, California required
laboratory reporting only for levels of 25 g/dl or
higher.\49

CDC found, in assessing the reporting requirements of selected states
and localities receiving CDC lead poisoning prevention and
surveillance grants, that 10 of 20 grantees had laws or
administrative rules requiring the reporting of all blood lead
levels.  A further discussion of CDC lead poisoning prevention
programs appears in appendix IV. 

Such data are important to have in targeting screening, since the
prevalence of elevated blood lead levels varies widely even among
communities within the same state or geographic area.  For example,
the Lead Poisoning Prevention Branch of the California Department of
Health Services has compiled data from several studies reviewing the
prevalence of elevated blood lead levels in various communities in
the state and found prevalence rates ranging from less than 5 percent
to more than 20 percent.  The branch concluded that this variability
reflects the complex structure of exposure sources and populations at
risk in the state.  A 1996 survey conducted by the Colorado
Department of Public Health and Environment similarly shows the
importance of local-level prevalence data for determining where to
target screening.  This survey assessed the prevalence of childhood
elevated blood lead levels in north central Denver and found a
prevalence rate much higher than expected.  Specifically, 16.2
percent of the 173 participating children had elevated blood levels,
more than five times the overall rate of 3.2 percent calculated from
1994 surveillance reports for Denver County, which encompasses
Denver.  The final report concluded that the findings were consistent
with the idea that there exist "pockets" of childhood lead poisoning
within the city.\50


--------------------
\49 Texas health department officials told us that although
laboratories found it easier to report all lead levels rather than
just those above 10 g/dl, the legislature thought that
requiring all results would be a burden. 

\50 See Richard Hoffman and others, Denver Childhood Blood Lead
Survey Final Report (Denver, Colo.:  Colorado Dept.  of Public Health
and Environment, Jan.  1996). 


      INTERVENTIONS TO IMPROVE
      IMMUNIZATION COVERAGE SHOW
      PROMISE FOR IMPROVING LEAD
      SCREENING
-------------------------------------------------------- Chapter 4:4.2

HHS' interventions to overcome some barriers to providing preventive
health services might serve as models and offer avenues for improving
lead screening.  Recent research has shown that the underimmunized
population and the population most at risk for elevated blood lead
levels are often the same.  Specifically, a March 1998 study found
that underimmunized children in inner cities are also at greater risk
for anemia and elevated lead levels.\51 Another study found that
children who were not up-to-date on their immunizations were likely
not to be up-to-date for lead screening.\52

HHS has found some avenues through its National Immunization Program
to reach the at-risk population.  The program seeks to increase
immunization rates in the preschool population through grants to each
state and 28 urban areas to implement immunization action plans.  In
1995, we reported on promising strategies for increasing
immunization, including provider-based strategies, such as assessing
clinic immunizations and offering feedback or creating reminder and
recall systems or registries to reduce missed opportunities for
immunization.\53 For example, over the past several years, CDC has
developed the Clinic Assessment Software Application to analyze
providers' records and diagnose immunization problems at their sites. 
Providers and other clinic personnel are then given feedback on their
immunization activities.  CDC studies show this strategy to be highly
effective in reducing missed opportunities and improving immunization
rates among children receiving care at clinics, and a CDC
immunization official told us that it may be feasible and reasonable
to modify the software to add the ability to review lead screening. 
Such promising strategies also include improving immunization rates
by coordinating immunization services with large public programs such
as WIC.  WIC is considered to be well suited to coordination with
immunization services, in part because participants typically visit a
program site with some regularity.\54 Since 1997, CDC has required
grantees to employ such strategies as a condition of receiving
immunization grant funding.\55 Further, since 1994, CDC has had in
effect a memorandum of understanding with USDA to emphasize the
importance of immunizing children who receive WIC benefits.\56

No similar agreement exists between CDC or HHS and USDA regarding
lead screening and treatment efforts.  According to a CDC Lead
Poisoning Prevention Branch official and officials from two health
departments we contacted, WIC program emphasis on lead screening has
decreased rather than increased since a 1993 change in USDA policy
regarding lead screening in WIC clinics.  In particular, a change in
CDC recommendations regarding allowable tests for conducting blood
lead screening required a change in WIC policy.  As a nutrition
program, WIC is required to screen participants for iron deficiency
anemia.  Until 1991, when CDC lowered the threshold of concern for
lead toxicity, a screening test commonly used to diagnose
anemia--called the erythrocyte protoporphyrin (EP) test--was also
considered adequate for identifying elevated blood lead levels. 
CDC's 1991 statement indicated that the EP test was not sensitive
enough to identify elevated blood lead levels under the new threshold
values.  Until this change of policy, WIC had encouraged agencies to
use the EP test for both anemia and lead screening, and many states
relied on WIC programs as primary providers for lead screening
services.  Following CDC's 1991 change in policy, a 1993 WIC
memorandum refocused WIC's role in the lead initiative from active
participation in screening to the more limited role of coordinating
with other local health programs such as EPSDT, establishing referral
systems, providing information and counseling, and developing
appropriate plans of nutritional care for children who are
affected.\57


--------------------
\51 William Adams and others, "Anemia and Elevated Lead Levels in
Underimmunized Inner-city Children," Pediatrics, Vol.  101, No.  3
(Mar.  1998), pp.  1-6. 

\52 Gerry Fairbrother and others, "Markers for Primary Care:  Missed
Opportunities to Immunize and Screen for Lead and Tuberculosis by
Private Physicians Serving Large Numbers of Inner-city
Medicaid-eligible Children," Pediatrics, Vol.  97, No.  6 (June
1996), pp.  785-90. 

\53 See Vaccines for Children:  Reexamination of Program Goals and
Implementation Needed to Ensure Vaccination (GAO/PEMD-95-22, June
1995). 

\54 Several studies have examined and reported on the benefits of
various strategies linking immunization to WIC participation.  See,
for example, Shefer and Mize and also Guthrie Birkhead, Helen
Cicirello, and John Talarico, "The Impact of WIC and AFDC in
Screening and Delivering Childhood Immunizations," Journal of Public
Health Management Practice, Vol.  2, No.  1 (1996), pp.  26-33. 

\55 We reported in 1997 on states' efforts to assess pockets of
children in need of immunization and their strengths and limitations. 
See CDC's National Immunization Program:  Methods Used to Identify
Pockets of Underimmunized Children Not Evaluated (GAO/HEHS-97-136R,
Aug.  1997). 

\56 Beginning with the fiscal year 1996 appropriation, the
Subcommittee on Labor, HHS, Education, and Related Agencies of the
Senate Appropriations Committee has recommended in report language
each year that CDC ensure that immunization grantees reserve 10
percent of funds for immunization assessment and referral services at
WIC sites. 

\57 See WIC policy memorandum 93-31. 


      MEDICAID MANAGED CARE OFFERS
      OPPORTUNITIES FOR INCREASING
      SCREENING RATES BUT MANY
      STATES HAVE YET TO ACT
-------------------------------------------------------- Chapter 4:4.3

The shift to managed care could add barriers to preventive health
services such as lead screening, since numerous concerns have been
raised about the extent to which Medicaid contracts with managed care
organizations contain specific EPSDT requirements.  However, research
is also finding that Medicaid managed care presents opportunities to
increase access to prevention and early intervention services.  State
Medicaid agencies have increasingly turned to managed care to cut
health care costs while ensuring health care access for Medicaid
enrollees.  From 1983 to 1996, Medicaid managed care enrollment grew
from around 750,000 to 13 million.  On the basis of reported numbers
from state Medicaid programs, we estimate that nationally 42 percent
of Medicaid recipients under the age of 6 were enrolled in managed
care plans as of June 30, 1997.\58

Concern has been raised about the extent to which children enrolled
in Medicaid managed care plans are receiving services in line with
EPSDT requirements.  In May 1997, HHS' Office of Inspector General
reported that only 30 percent of the children 5 years old and younger
who were enrolled in managed care plans received all EPSDT services
specified in the state periodicity schedule.  Nearly 50 percent of
this group received no EPSDT services at all.  The Inspector General
recommended that HCFA (1) revise its EPSDT reporting requirements and
data collection to emphasize the number of children who receive all
their EPSDT screens in a timely fashion, (2) encourage states to
actively notify managed care plans of enrollees due for EPSDT exams
and follow-up if EPSDT services are not rendered shortly thereafter,
(3) work with states to ensure timely managed care EPSDT reporting,
and (4) emphasize to states the need to define and clarify EPSDT
requirements in their Medicaid contracts with managed care plans.  An
Inspector General official indicated that HHS was taking appropriate
steps to implement these recommendations and that the Office of the
Inspector General was continuing its monitoring of the
recommendations. 

Recent research has shown that many Medicaid contracts with managed
care organizations still do not address lead screening.  In August
1998, the George Washington University Center for Health Policy
Research reported on provisions on childhood lead poisoning
prevention services in Medicaid managed care contract documents (for
contracts in effect during 1997).\59 The center reported that only 20
of the 42 contract documents it reviewed contained language
addressing managed care organization duties related to lead-related
care, primarily screening.  The center also reported that contract
documents rarely identified lead-related services either with respect
to quality assurance or as a specific reporting duty. 

In contrast, this study and others have found that some states have
used their managed care contracts to build in EPSDT performance
measures at the outset.  According to a recent survey, 21 of 31
states reviewed that have managed care programs include performance
targets in their contracts.\60 Hence, the contracts are vehicles
through which state Medicaid agencies can set specific reporting
standards and require the providers to submit data to measure their
performance.  For example, Wisconsin has established performance
goals in its managed care contracts, including specific goals for
blood lead screening, and has required managed care organizations to
report data to measure this performance.  The state has set as a
performance goal that managed care organizations have an 85-percent
lead screening rate by 1999.  Annually, the state reports performance
comparisons for managed care and non-managed-care providers.  The
1995 comparison report found that managed care enrollees under age 5
received more preventive care screens than those receiving
fee-for-service care.  Lead testing among managed care enrollees was
almost twice as high as in the fee-for-service population (11.9
percent versus 6.9 percent).  According to the George Washington
University report, 11 of 42 contracts reviewed contained language
establishing some type of quality or performance standards relating
specifically to lead. 


--------------------
\58 HCFA does not record data on the extent to which state Medicaid
programs have children in this age group enrolled in managed care
arrangements.  We derived this estimate from the responses to our
survey of state Medicaid directors, who reported on children under
age 6 (1) in Medicaid managed care and (2) in total covered by
Medicaid as of June 30, 1997. 

\59 See Elizabeth Wehr and Sara Rosenbaum, Medicaid Managed Care
Contracting for Childhood Lead Poisoning (Washington, D.C.:  Center
for Health Policy Research, School of Public Health and Health
Services, George Washington University Medical Center, Aug.  31,
1998). 

\60 See Rosenbach and Gavin, "Early and Periodic Screening,
Diagnosis, and Treatment and Managed Care," Annual Review of Public
Health, No.  19 (1998), pp.  507-25. 


SEVERAL PROBLEMS HINDER TIMELY
FOLLOW-UP TREATMENT AND OTHER
SERVICES
============================================================ Chapter 5

Once children's elevated blood lead levels are identified, it is
important that they receive follow-up services, which can be complex
and resource intensive but according to experts are necessary to
minimize adverse health effects.  CDC's recommended follow-up
services include periodic retesting to ensure that lead levels
decline and, for children who have higher levels, clinical
management, care coordination, and other services such as
investigations to determine the source of lead exposure.  CDC
believes that data collected on the provision of follow-up services
are not reliable and, therefore, the extent to which these services
are provided to children who have elevated blood lead levels is
largely unknown.  Our work at health centers and health departments
across the country showed gaps in the timeliness of follow-up testing
and other services:  Providers miss opportunities to perform more
timely follow-up tests, children do not return to the health center,
and parents do not comply with providers' orders to have tests
conducted.  Another key problem is that state Medicaid policies often
do not support paying for services that CDC recommends for treating
children who have elevated lead levels, and most programs lack formal
arrangements with other health or housing agencies regarding the
treatment of children who are enrolled in Medicaid and have elevated
blood lead levels.  Having established relationships between
providers and health and other agencies may become even more
important as increasing numbers of children are covered under
Medicaid managed care. 


   RECOMMENDED FOLLOW-UP SERVICES
   CAN BE COMPLEX AND RESOURCE
   INTENSIVE
---------------------------------------------------------- Chapter 5:1

Public health experts consider follow-up testing and case management
of children who have elevated blood lead levels to be important
aspects of treatment, particularly to ensure that blood lead levels
do not continue to rise.  According to the American Academy of
Pediatrics, the amount and duration of a child's exposure to lead are
key factors in toxicity levels.  Early detection and source control
are therefore important to minimizing adverse consequences.\61
Follow-up care for children identified with elevated blood lead
levels is considered uniquely multidisciplinary, requiring close
coordination between a child's health care provider, local public
health department, and others.  CDC indicates that to treat children
for elevated blood lead levels, the lead source must be identified
and controlled.  Identifying how a child has been exposed to lead and
preventing recurring exposure can be complex and may involve many
more parties than the child's health care provider.  Because
childhood lead exposure is likely to be associated with poor and
deteriorating communities, children who have elevated blood lead
levels may also lack adequate housing, routine medical care, and good
nutrition.  CDC's recommended treatment approaches vary depending on
a child's blood lead level: 

  -- CDC's recommended follow-up for levels between 10 and 19
     g/dl--the range in most children who have elevated
     blood lead levels--is generally to test at least every 3 to 4
     months, make referrals for social services, educate families
     about lead, and possibly provide clinical management and
     environmental investigations if the elevation persists.\62

  -- For children whose lead levels are 20 g/dl or higher,
     CDC indicates that it is critical to reduce a child's exposure
     to lead.  It recommends care coordination and investigations to
     determine the source of lead.  CDC also recommends clinical
     management, including a clinical evaluation of the child's
     medical history and history of housing and other environmental
     sources of exposure, the correction of nutrition problems, and a
     physical examination to identify language delay or other
     neurobehavioral or cognitive problems that should be referred to
     other appropriate programs.  Children who have extremely high
     lead levels (45 g/dl or higher) may need drugs to help
     reduce the lead toxicity, a treatment known as chelation
     therapy.\63

For children in need of comprehensive services, CDC recommends that a
follow-up team address the complex and resource-intensive care
required.  The team should consist of the child's health care
provider, a care coordinator, a community-health nurse or nurse
adviser, an environmental health specialist, a social services
liaison, and a housing specialist.  Generally, the child's health
care provider monitors the child's blood lead levels, provides the
direct medical treatment such as chelation therapy, and addresses any
other medical or developmental issues that may arise.  The
community-health nurse or nurse adviser visits the child's home,
interviews the family about possible lead sources, educates the
family about ways to reduce lead exposure, and links the family to
other services.  The environmental health specialist investigates the
child's environment, testing paint and taking other samples as needed
to find and eliminate the source of poisoning.  See appendix IV for
further information on federal policies for treating children who
have elevated blood lead levels. 

The federal government has several other roles in lowering blood lead
levels.  Federal Medicaid law requires that state Medicaid programs
cover any treatment or other medical assistance necessary to "correct
or ameliorate" physical and mental illnesses and conditions
discovered through an EPSDT screen.  This law has been at issue in
numerous lawsuits related to defining "medically necessary" care.\64
Determining what constitutes medical treatment for an environmentally
caused condition can be difficult.  HCFA has indicated that at a
minimum investigations to determine the source of lead exposure are
important in treating a child diagnosed with an elevated blood lead
level.  HCFA and HRSA policies governing state Medicaid and health
center programs generally recommend that providers follow CDC's
recommendations.\65 CDC grants for lead poisoning prevention and
surveillance (usually awarded to state and local health departments)
entail responsibilities for tracking and ensuring follow-up care. 


--------------------
\61 See the statement of the American Academy of Pediatrics,
Committee on Environmental Health, "Screening for Elevated Blood Lead
Levels," Pediatrics, Vol.  101, No.  6 (June 1998), pp.  1072-78. 

\62 In its 1991 guidelines, CDC recommended that tests showing blood
lead levels of 10 g/dl or higher should be repeated in 3 to
4 months or less, depending on the lead level--the higher the level,
the more frequent the testing.  In its 1997 guidelines, CDC
recommended even more frequent follow-up testing (retesting at 1- to
2-month intervals until blood lead levels have declined, lead hazards
have been removed, and there are no new exposures).  CDC also
recommends clinical management and environmental investigation when
two consecutive blood levels at least 3 months apart measure 15
g/dl. 

\63 In chelation therapy, drugs bind or chelate lead, thus reducing
its acute toxicity. 

\64 See National Health Law Program and Texas Rural Legal Aid, Toward
a Healthy Future--Early and Periodic Screening, Diagnosis, and
Treatment for Poor Children (Los Angeles, Calif.:  Apr.  1995). 

\65 HCFA leaves discretion to providers with reference to CDC's
guidelines.  HRSA requires that health centers establish a protocol
for following up abnormal results and indicates that health care
providers may use their professional judgment with respect to CDC's
guidelines. 


   NATIONAL DATA ARE LACKING, BUT
   HEALTH CENTERS AND HEALTH
   DEPARTMENTS VARY IN PROVIDING
   TIMELY SERVICES
---------------------------------------------------------- Chapter 5:2

No national database exists for reliably determining the extent to
which follow-up services are provided.  CDC requires its grantees to
report on the environmental inspection of the homes of children who
have elevated blood lead levels and on medical case management
activities such as the number of new cases identified, children
treated with chelation therapy, and cases closed.  CDC officials
indicated that this information is often incomplete and inconsistent. 
As a result, they said, it is generally not useful to compare
performance or draw generalizations about progress.  CDC officials
indicated that they were reevaluating the data requirements and
planned to issue new requirements in 1999. 


      HEALTH CENTERS VARY IN
      FOLLOW-UP TESTING
-------------------------------------------------------- Chapter 5:2.1

Our reviews at six health centers across the country showed
differences in the extent to which providers conduct follow-up tests
and the extent to which these are performed in line with CDC's
recommendations.\66 At all six centers, some children had no
follow-up tests after the initial diagnosis of elevated blood lead
levels.  When we visited the centers in late 1997 and early 1998, 32
of the 102 children in our sample whose elevated blood lead levels
had been identified in 1996 had not yet received any follow-up tests. 
Table 5.1 shows that the extent of sampled cases that did not receive
follow-up tests ranged from 9 percent to 62 percent at the six health
centers.\67



                         Table 5.1
          
              Extent to Which Children Who Had
             Elevated Blood Lead Levels Did Not
           Receive Follow-Up Tests at Six Health
                          Centers

                                                Percent of
                                          children who had
                                            elevated blood
                                           lead levels and
                                               received no
Health center site                       follow-up tests \
--------------------------------------  ------------------
Atlanta, Ga.                                            62
Brooklyn, N.Y.                                          13
New Bedford, Mass.                                      32
Philadelphia, Pa.                                       20
San Antonio, Tex.                                       25
Watsonville, Calif.                                      9
----------------------------------------------------------
Almost half of the follow-up blood tests for the 102 children whose
medical records we reviewed were not conducted within CDC's
recommended time period.\68 The percentage of untimely follow-up
testing at the six health centers ranged between 19 and 66 percent,
as shown in table 5.2. 



                         Table 5.2
          
           Percentage of Untimely Follow-Up Blood
              Lead Tests at Six Health Centers

                                        Percent of follow-
                                              up tests not
                                          conducted within
                                         CDC's recommended
Health center site                          time periods\a
--------------------------------------  ------------------
Atlanta, Ga.                                            66
Brooklyn, N.Y.                                          19
New Bedford, Mass.                                      54
Philadelphia, Pa.                                       39
San Antonio, Tex.                                       48
Watsonville, Calif.                                     29
----------------------------------------------------------
\a While we looked for follow-up tests within 4 months of the
elevated blood level test, we found that in 58 of the 70 situations
in which a test had not been conducted within 4 months, the test had
also not been conducted even after 6 months.  See appendix V for
information on the criteria used for evaluating the timeliness of
follow-up tests. 

The clinic in Everett, Washington, was largely not conducting lead
screenings and thus had not identified any elevated blood lead levels
for follow-up.  According to the Washington State Department of
Health lead registry, which contains all statewide blood lead test
results, less than 40 percent of children who had blood lead levels
between 10 and 19 g/dl in 1996 received timely follow-up
testing.  The department reported in June 1997 that about one-third
of the tests conducted in the past year for children whose levels
were 20 g/dl and higher were not followed up with subsequent
retests.  It is at these levels that CDC recommends more intensive
follow-up, including clinical management and environmental
investigations to determine the source of lead. 


--------------------
\66 We exclude Everett, Washington, because virtually no screening
tests for lead were conducted there. 

\67 Some state Medicaid agencies and other researchers have similarly
examined follow-up testing and treatment.  For example, a 1996
Minnesota review of Medicaid screening and follow-up activities found
that 18.4 percent of children who had elevated blood lead levels had
received no documented intervention. 

\68 We reviewed the medical records of children who had elevated
blood lead levels in 1996 to assess whether follow-up tests were
performed with the frequency recommended in CDC's 1991 guidelines. 
We used the 1991 guidelines since the cases were drawn from a time
period before CDC's November 1997 guidelines.  Since some children
did receive several follow-up tests, we based timeliness on the
percentage of tests showing an elevated blood lead level that were
followed by a subsequent test in the recommended time.  We discuss
our methodology and findings in appendix V. 


      HEALTH DEPARTMENT CASE
      STUDIES SHOW VARIATION IN
      TRACKING CHILDREN WHO HAVE
      ELEVATED BLOOD LEAD LEVELS
-------------------------------------------------------- Chapter 5:2.2

We evaluated certain cases to determine how CDC-supported lead
poisoning prevention and surveillance programs tracked them and
ensured that the children received needed services.\69 Specifically,
for diagnoses of lead levels 20 g/dl or higher, we
determined what the CDC-supported lead poisoning programs (managed by
the state or local health department) reported on the services they
provided to the children.\70 While all but one of the state and local
health departments had records of some of or all the cases we
tracked, they varied widely in the extent to which they documented
activities to ensure follow-up services.  For example, for the three
children in Brooklyn whose blood lead levels were 20 g/dl or
higher, the CDC-supported lead poisoning prevention program at the
New York City Health Department documented significant activity in
terms of home visits and environmental inspections and other action
to address the identified lead hazards.  In contrast, according to
state and local health officials, the two children identified with
levels of 20 g/dl or higher in Atlanta were not reported to
the state or local health departments for follow-up.  We could find
no evidence that any follow-up testing or other services were
provided to these children.  Table 5.3 details the results of our
case studies at the seven health center sites. 



                               Table 5.3
                
                    Health Department Follow-Up and
                 Monitoring Activities for Children Who
                Had Blood Lead Levels of 20 g/
                              dl or Higher

Health center
site              Case status
----------------  ----------------------------------------------------
Atlanta, Ga.      The two cases of 20 g/dl or higher were not
                  recorded in the state lead registry of laboratory
                  reports on elevated blood lead levels, despite state
                  law requiring such information. Neither the state
                  nor the local health department was aware of these
                  two cases and thus no follow-up activities,
                  including testing, had been conducted by either
                  organization. After our visit, the health center
                  reported the cases to the health department.

Brooklyn, N.Y.    The three cases were reported to the local health
                  department, which made between three and six
                  attempts to inspect each home for lead, successfully
                  inspecting each home at least twice. In each case,
                  the medical provider was contacted, an order to
                  abate the lead was issued, and an inspector observed
                  that the abatement was completed.

Everett, Wash.    We did not test the Washington state system for
                  tracking cases since we did not take a sample at the
                  health center there. However, state health
                  department officials told us that the state
                  conducted environmental investigations for all
                  children whose blood lead levels were higher than 20
                  g/dl because most local health departments,
                  which had this responsibility, did not have adequate
                  resources to do so. The state health department
                  reported that in 1997 16 children were diagnosed
                  with levels higher than 20 g/dl and that as
                  of August 1998 9 had received home investigations,
                  the cases of 3 had been closed, and the remaining 4
                  had not received follow-up for unknown reasons.

New Bedford,      The state health department had records of all four
Mass.             cases in our sample and had conducted at least one
                  home inspection in each case. The lead in one
                  child's residence was abated, one child had moved,
                  and two children's residences had no lead paint
                  violations.

Philadelphia,     The local health department had records of all four
Pa.               cases in our sample and had records of environmental
                  investigations in two of the four cases. For one of
                  the other cases, the health department had no record
                  of the laboratory tests that indicated a blood lead
                  level high enough to trigger an environmental
                  evaluation. In the other case, an investigation was
                  attempted and four visits were attempted or letters
                  were sent but the health department was unsuccessful
                  in contacting the child, inspecting the home, or
                  otherwise intervening.

San Antonio,      The state health department had records of all four
Tex.              children in our sample but did not maintain
                  information on home visits or other follow-up
                  activities apart from blood tests. The local health
                  department indicated that, in one case, the child's
                  home was visited and an environmental investigation
                  was performed and reported to the provider and the
                  parents. Since the local health department did not
                  have records for the three other children in our
                  sample, we could find no evidence of follow-up
                  activities other than lead testing.

Watsonville,      The state health department had records for the two
Calif.            children whose lead levels were 20 g/dl or
                  higher. It contracted with and paid most local
                  health departments to conduct case management of
                  children diagnosed with elevated blood lead levels.
                  The local health department records for both
                  children showed at least three home visits, but
                  because exposure sources could not be validated,
                  activities to address the lead had not been
                  conducted. Both children had visited or lived in
                  Mexico and been exposed to potential lead sources
                  such as candy and pottery.
----------------------------------------------------------------------
Note:  Appendix VII discusses differences in states' legal
infrastructure for reporting elevated blood lead levels and for
requiring lead abatement activities. 


--------------------
\69 Differences in services may to some extent reflect differences in
the two types of CDC grant programs--for lead poisoning prevention
and for surveillance--and their associated funding levels.  While
both types of grant applications are evaluated in part for plans or
systems to help ensure the follow-up of children, a CDC official
indicated that unlike prevention grants, surveillance grants have a
funding limit of $95,000 and usually do not support health education,
public health nurses, or environmental personnel.  Washington and
Texas were receiving surveillance grants at the time of our review,
and New York City and the states of California and Massachusetts were
receiving prevention grant funding.  Georgia was not receiving CDC
funding at the time of our review, but it did receive prevention
grant funding in 1996.  Philadelphia was receiving some CDC funding
through the Pennsylvania grant. 

\70 Four or fewer children had blood lead levels of 20 g/dl
or higher in our samples at each health center location.  We asked
state and local health departments tracking cases for those health
center locations to provide information from their systems on these
cases, including the date of the first investigation of the child's
home or environment to identify sources of lead, the number of visits
to the home made by health officials such as public health nurses,
the number of inspections of the home and other contacts, and whether
any activities addressed the source of lead. 


   BARRIERS TO ENSURING THAT
   CHILDREN WHO HAVE ELEVATED
   BLOOD LEAD LEVELS RECEIVE
   TIMELY FOLLOW-UP
---------------------------------------------------------- Chapter 5:3

We identified numerous barriers to conducting timely follow-up
testing and other services that CDC recommends.  As with screening,
key barriers include missed opportunities to perform follow-up tests
when children return to a health center and losing children to
follow-up because they do not return to the health center or because
their parents do not comply with the provider's order for follow-up
blood lead tests. 


      PROVIDERS MISS OPPORTUNITIES
      TO PERFORM FOLLOW-UP TESTS
-------------------------------------------------------- Chapter 5:3.1

Many health center providers miss opportunities for timely follow-up
tests when children return for other care.  All the health centers we
reviewed had written protocols for the providers to use in
determining appropriate follow-up treatment, most of which
recommended follow-up tests for children whose blood lead levels are
10 g/dl or higher, at increasing frequency the higher the
lead level.  The follow-up tests could be scheduled in separate
appointments or conducted in conjunction with other types of visits
children made to the center.  At six of the seven health centers,
however, providers often did not perform tests within the recommended
time periods even though the children visited a center for other
care.  (See table 5.4.)



                         Table 5.4
          
          Missed Opportunities to Provide Follow-
                          Up Tests

                                           Percent of late
                                            tests in which
                                           follow-up could
                                            have been done
Health center site                                  sooner
--------------------------------------  ------------------
Atlanta, Ga.                                            42
Brooklyn, N.Y.                                          20
New Bedford, Mass.                                      47
Philadelphia, Pa.                                       27
San Antonio, Tex.                                       33
Watsonville, Calif.                                     25
----------------------------------------------------------

      CHILDREN DO NOT RETURN FOR
      FOLLOW-UP CARE
-------------------------------------------------------- Chapter 5:3.2

Health center officials told us that since the population they serve
tends to be transient, children often do not return for services. 
Our review of the medical records supports this observation and the
providers' concern that some follow-up issues are beyond their
control.  In 22 of the 102 cases reviewed, the children never
returned after the elevated blood lead level was identified. 

Another associated problem beyond the control of health care
providers is that parents do not always comply with their orders for
follow-up blood tests.  As with screening tests, parents may be
required, as they are in California, to take their children to
another location for tests.  In 12 of 102 cases we reviewed, we found
that the provider ordered a blood test but that there was no
indication the test was conducted. 


   STATE MEDICAID PROGRAMS OFTEN
   DO NOT REIMBURSE OR FORMALLY
   COORDINATE KEY FOLLOW-UP
   SERVICES
---------------------------------------------------------- Chapter 5:4

Medicaid law requires the states to cover treatment and other medical
assistance necessary to correct or ameliorate conditions identified
through EPSDT screening tests (such as elevated blood lead levels). 
However, our review indicates that the states are considering their
coverage for certain treatment and follow-up services deemed
important by CDC and HCFA as optional.  In addition, most state
Medicaid agencies lack formal agreements with health departments and
other agencies involved in funding, tracking, and providing screening
and treatment services.  Such collaborations may be increasingly
important as managed care arrangements cover increasing numbers of
children in Medicaid, but recent research indicates that state
Medicaid agencies have yet to consider the need for such
collaborations in their managed care contracts. 


      FEWER THAN HALF OF STATE
      MEDICAID AGENCIES REIMBURSE
      FOR KEY FOLLOW-UP SERVICES
-------------------------------------------------------- Chapter 5:4.1

In our survey of 51 state Medicaid programs, we found that many lack
policies to cover investigative services to determine the source of
lead exposure or care coordination and case management to ensure that
children who have elevated blood lead levels receive the social,
environmental, and other services they need.\71 While all the
programs except one cover follow-up testing by public or private
laboratories or other entities, only 23 reimburse for investigative
services to determine the source of lead exposure, and 20 reimburse
for case management and care coordination.  Only 14 states reported
that the state Medicaid program reimburses for both.\72

As with screening, part of the reason why state Medicaid programs are
not following HCFA policy may be unclear EPSDT policies coupled with
the difficulty of determining what are "medically necessary"
treatment services for children with an environmentally caused
condition.  HCFA has in the past supported CDC's position that
investigative services are important to treating elevated blood lead
levels but has not taken the position in regulations or policy that
all states are expected to cover such services or case management
specifically for lead-poisoned children.  In line with CDC's
recommendations, HCFA in a 1992 memorandum to regional offices
indicated that locating the source of lead is an "integral part of
the management and treatment of a child diagnosed with an elevated
blood lead level." However, in this memo HCFA also indicated that
investigation "may" be a covered Medicaid benefit, and other
references in HCFA's Medicaid manual and memos use similar language
in indicating that investigation "may" be a covered service. 

As one of the few states where the Medicaid program covers lead
investigations, case management, and other services for children who
have elevated blood lead levels, California provides an example of a
state health department that has worked to ensure that adequate
resources are available and that responsibilities are coordinated for
treating lead-poisoned children.  The Childhood Lead Poisoning
Prevention Branch of the California Department of Health Services
helps provide for screening, care coordination, environmental
investigation, and other services for California's at-risk children. 
The program is partly supported by fees assessed on industries that
have contaminated the environment with lead.  The program has also
negotiated reimbursements for costs associated with case management
activities for children in Medicaid who have elevated blood lead
levels and contracts with local health departments to perform such
activities.  In addition to case management and environmental
inspection, the program has arranged for state Medicaid coverage of
medical nutrition therapy and outreach and interagency coordination
of blood lead testing and follow-up services.  Data from California's
lead exposure surveillance system indicate that environmental
investigations are performed in 95 percent of cases of lead-poisoned
children. 


--------------------
\71 These policies may also be affecting screening rates.  Health
officials in some locations indicated that children are not screened
in part because of insufficient resources and mechanisms for
addressing elevated blood lead level cases.  A 1992 survey of state
health officers conducted by the Association of State and Territorial
Health Officials found that major reported barriers to screening were
insufficient resources for environmental follow-up and abatement. 

\72 In the absence of a state policy for covering such services, the
state may still be obligated under Medicaid law to reimburse for
treatments or other forms of medical assistance that providers deem
necessary to address a child's health condition.  However, it may
then be incumbent on beneficiaries and providers to seek payment for
such services.  According to the April 1995 report of the National
Health Law Program and Texas Rural Legal Aid, states that have not
previously covered a service in their state plan are likely to lack
processes to handle requests for coverage and claims payment. 
According to this report, in these cases, the lack of an approval
process often means that when a claim is submitted it will be handled
by denying coverage for treatment or that providers do not submit
claims for services in the first place. 


      FEW STATE MEDICAID AGENCIES
      REPORT FORMAL COLLABORATIONS
      WITH OTHER AGENCIES
-------------------------------------------------------- Chapter 5:4.2

Another tool for helping ensure that services are provided is a
formal agreement between the state Medicaid agency and the health
departments, housing departments, or others with responsibilities for
paying for and providing services to children who have elevated blood
lead levels.  In our survey, only ten state Medicaid programs
reported having such arrangements by providing documentation of
agreements.  The 1994 evaluation of CDC's Lead Poisoning Prevention
Branch found that although collaborative links to address the needs
of children are essential for both policy and service delivery, few
CDC grantees had been successful in building such links.\73 How well
applicants for CDC grants demonstrate collaboration with important
partners such as state Medicaid programs to ensure that adequate
services are provided to children who have elevated blood lead levels
is only a small part of application evaluations.\74 Further, how or
whether Medicaid agencies collaborate with CDC grantees or public
health departments is not routinely reviewed. 

Formal collaborations work well in Rhode Island.  The state's health
department and its Department of Human Services (which administers
the Medicaid program) have a formal agreement regarding
responsibilities for case management payments, and the departments
were actively collaborating at the time of our review to develop
"lead centers" to provide comprehensive services to the state's
children diagnosed with lead poisoning.  Initial proposals were that
such centers would provide intensive case management, assist families
with housing, conduct housing inspections, educate parents, offer
education on proper cleaning techniques, and make referrals for
coordinating all needed medical and nutrition services. 


--------------------
\73 Macro International, Inc., Executive Summary. 

\74 CDC indicated that it weighted collaboration more heavily in 1997
than in earlier years. 


      MEDICAID MANAGED CARE
      PRESENTS CHALLENGES AND
      OPPORTUNITIES TO IMPROVE
      TREATMENT SERVICES
-------------------------------------------------------- Chapter 5:4.3

Formal coordination between Medicaid and other agencies may become
even more important as increasing numbers of children in Medicaid are
covered by managed care arrangements, changing traditional health
department and provider roles for ensuring treatment services.  On
the one hand, some health departments and others are concerned that
many managed care organizations are not set up to handle the
coordination of care that is expected as the major treatment for
children who have elevated blood lead levels.  On the other hand, the
availability of a "medical home" for children in managed care
arrangements may enhance the continuity of care and offer a network
of providers not otherwise available or easily accessible.\75

Recent research indicates that state Medicaid agencies have largely
not considered how managed care organizations should coordinate with
health departments and others in treating children who have elevated
blood lead levels and other conditions.  The 1998 study of Medicaid
managed care contracts supported by CDC and conducted by the Center
for Health Policy Research of the George Washington University
Medical Center identified concerns about the extent to which managed
care contracts clarified expectations regarding the coordination of
care.  The center found that very few Medicaid contract documents
addressed either medical follow-up for children for whom screening
showed elevated blood lead levels or the integration of medical
follow-up with public health agency activities to identify and reduce
lead hazards in these children's homes.  The study reported that
while managed care is viewed as a means of providing a medical home
for children in Medicaid and creating administrative systems for
tracking and ensuring the provision of care, many states have yet to
really grasp the potential of managed care to improve the quality of
lead-related treatment services.\76

Our visits to two programs known for model case management of
children who have elevated blood lead levels also found evidence of
changing roles: 

  -- Officials at the Kennedy Krieger Institute in Baltimore,
     Maryland, told us that their program for treating children for
     elevated blood lead levels depends largely on Medicaid funding
     and had seen a decline of more than 50 percent in patient
     referrals in 1 year since the state had implemented managed care
     within its Medicaid population.  Officials expressed concern
     that managed care organizations would attempt to address the
     treatment of lead-poisoned children on their own without
     adequate knowledge of its complexities. 

  -- Officials at the Westchester County Health Department in New
     York indicated that since managed care had been implemented
     there in 1995, their role regarding children who have elevated
     blood lead levels had changed significantly.  Before 1995, the
     county was the local entity responsible for case management for
     all lead-poisoned children.  With the advent of managed care,
     the county both acts as a subcontractor of managed care
     plans--contracted to perform case management services--and
     oversees the performance of managed care plans' screening and
     treatment activities.  Officials indicated that a major
     challenge was to determine the effect of Medicaid managed care
     on lead screening and case management.  They said that they were
     developing methods of monitoring managed care organization
     activities to ensure that children who have elevated blood lead
     levels receive needed care. 


--------------------
\75 See Rosenbach and Gavin. 

\76 Wehr and Rosenbaum. 


CONCLUSIONS, RECOMMENDATIONS, AND
AGENCY COMMENTS AND OUR EVALUATION
============================================================ Chapter 6


   CONCLUSIONS
---------------------------------------------------------- Chapter 6:1

The past success in dramatically reducing the number of children who
have elevated blood lead levels has created new challenges for
addressing this public health problem.  Despite low screening rates,
the number has been reduced by eliminating lead sources in gasoline,
food sources, and paint.  Today, most children who have elevated
blood lead levels have relatively low levels compared with levels in
earlier years.  However, research is increasingly showing that even
low levels of lead present a significant cost to children's potential
and to their families, educators, and society at large.  Since most
children who have elevated blood lead levels are likely to have no
overt symptoms, lead poisoning is a silent problem whose solution
depends on proactive efforts to identify it.  Identifying the
children among the millions who are considered to be at risk because
they live in poverty or older homes requires the concerted effort of
public health officials, providers, and parents.  New information
points to a need for more diligent state and federal program
involvement to ensure that at-risk children are screened and treated. 
National data show that most of the 890,000 young children who are
estimated to have elevated blood lead levels have not been screened
for lead and remain undetected, and most of these children are served
by federal health care programs. 

The federal role has been to set policies and requirements for
federally supported health financing and service delivery programs
and to support lead poisoning surveillance and prevention through
grant programs.  However, these programs do not yet ensure that
screening and follow-up occurs.  State implementation of federal
policies has been spotty, and low national screening rates even
within federal health care programs requiring periodic screening
services reflect barriers to screening and treating children.  The
services that children receive also vary widely across the country,
depending partly on whether state Medicaid agencies cover services
such as investigations to determine the source of lead exposure and
whether states and localities have passed laws and established
systems to ensure that necessary services are received.  While
variation between states' programs and screening rates may be
warranted to the extent that the risk for elevated blood lead levels
varies between states and even within a state, most states lack
representative, reliable prevalence and screening data upon which to
make good determinations of who should and should not be screened. 

HHS has done little to monitor the provision of lead screening
services to children in federal health care programs, and state
Medicaid programs often do little to monitor providers' compliance
with federal screening policies.  Improving federal monitoring of
state and providers' compliance is one option for improving
screening.  However, the success of such efforts may be limited, if
providers remain unconvinced that lead poisoning is a risk to the
children they serve.  Therefore, ensuring the availability of data to
more conclusively establish the extent of the risk and to target
limited resources is an important federal role.  Representative,
reliable local data on the extent to which children have elevated
blood lead levels would help providers identify them more cost
effectively and would help convince parents and providers of the need
to screen.  Such data could also be used to give federally supported
health care programs more flexibility in basing their screening
policies on the best available local data on children at risk. 

The biggest challenge to meeting the HHS goal of eliminating lead
poisoning by 2011 may be coordinating the efforts of the many players
that help address this environmental health condition.  Coordination
must start at the federal level with those who set federal lead
screening and treatment policies.  Although managed care may
complicate coordination as traditional health care delivery roles
change, it also offers the opportunity to ensure that children
receive a wider range of preventive health and treatment services by
providing the opportunity to clarify expectations about providers'
performance in managed care contracts. 

Lead screening could also increase if more at-risk children used
preventive health care services and if interventions for improving
access to various services were integrated.  In recent years, the
federal government has supported state development of interventions
such as the use of WIC clinics to ensure that children are immunized
and systems for assessing providers' immunization rates.  These
efforts could serve as models or avenues for increasing lead
screening. 


   RECOMMENDATIONS
---------------------------------------------------------- Chapter 6:2

To improve federal efforts to ensure that federal health care
programs reach at-risk children in need of screening and treatment
for elevated blood lead levels, we are making a number of
recommendations.  These recommendations would improve (1) the
information at the state and local levels needed to better target
screening efforts to those at highest risk, (2) enforcement and
monitoring of federal screening and treatment policies, (3) state
Medicaid contracts with managed care organizations, (4) the policies
regarding services that children who have elevated blood lead levels
should receive, and (5) the coordination between lead poisoning
screening and treatment efforts and other preventive health care
programs. 


      IMPROVING INFORMATION
-------------------------------------------------------- Chapter 6:2.1

To improve the awareness of providers and the public about the
prevalence of elevated blood lead levels among young children in
their communities and to enhance the effectiveness of targeted
screening efforts, HCFA and CDC should work more closely with state
Medicaid and CDC-supported programs to encourage information-sharing
and the development of data needed to better identify at-risk
children.  Specifically,

  -- state Medicaid programs should be encouraged to work with state
     health departments to develop systems to identify the prevalence
     of elevated blood lead levels among children in Medicaid and

  -- CDC should require grant applicants to (1) demonstrate that they
     have, or have systems to obtain, representative, reliable data
     on the prevalence of elevated blood lead levels in their states
     or communities or to commit to conducting periodic surveys to
     obtain such data and (2) commit to developing mechanisms for
     distributing such information to the public and providers. 


      IMPROVING SCREENING RATES
-------------------------------------------------------- Chapter 6:2.2

To improve screening rates within federal health care programs, HCFA
and HRSA should improve the monitoring of adherence to federal lead
screening policies within the Medicaid and Health Center programs. 
Specifically,

  -- HCFA should require state Medicaid agencies to report on the
     lead screening services that are provided to children within the
     EPSDT program and to document progress in meeting lead screening
     performance goals.  HCFA should require the states that do not
     meet expectations to develop plans for improving their
     performance. 

  -- HRSA should use current monitoring mechanisms to better ensure
     that health centers follow all federal lead screening policies. 

  -- HCFA and HRSA should develop a process for waiving universal
     lead screening requirements when state programs can demonstrate
     that they have representative and reliable data and data systems
     upon which to base local policies. 


      IMPROVING MANAGED CARE
      CONTRACTS
-------------------------------------------------------- Chapter 6:2.3

To ensure that state Medicaid agencies' managed care contracts
clearly delineate appropriate lead screening and treatment
responsibilities, HCFA and CDC should work together to provide
guidance to state Medicaid agencies on including lead screening and
treatment protocols in managed care contracts. 


      IMPROVING REIMBURSEMENT FOR
      SERVICES
-------------------------------------------------------- Chapter 6:2.4

To ensure that state Medicaid agencies more consistently provide for
reimbursement for services for lead-poisoned children, HCFA should
clarify in regulation or Medicaid policy the expectation that, in
line with CDC recommendations, all state Medicaid agency EPSDT
programs include reimbursements for investigations to determine the
source of lead exposure and case management services for children
identified with elevated blood lead levels.  Further, HCFA should
consult with CDC to delineate and clarify its expectations for the
other services it deems medically necessary to treat children who
have elevated blood lead levels. 


      INTEGRATING LEAD SCREENING
      WITH OTHER PREVENTIVE HEALTH
      CARE FOR CHILDREN
-------------------------------------------------------- Chapter 6:2.5

To improve the efficiency and effectiveness of lead screening and
other preventive health care efforts and to marshal federal health
care resources for reaching at-risk children, HHS should explore
options for better coordinating interventions to improve lead
screening with other preventive health services such as immunization. 
One such option HHS should consider would establish a formal
agreement or requirements for coordinating HHS' lead screening and
treatment activities with those of the WIC program. 


   AGENCY COMMENTS AND OUR
   EVALUATION
---------------------------------------------------------- Chapter 6:3

HHS commented on a draft of our report in a December 22, 1998,
letter.  HHS generally agreed with the recommendations of the report. 
HHS provided several technical comments, which were incorporated into
our report as appropriate, and several clarifications and
qualifications, which are discussed below.  HHS' letter is printed in
appendix VIII. 

HHS agreed with our conclusion that managed care presents additional
opportunities to improve Medicaid services for lead screening and
treatment.  However, HHS did not agree with our conclusion that the
transition to managed care may also complicate efforts toward
coordinating the many players needed to address lead poisoning,
indicating that the report does not provide evidence of such a
conclusion.  As discussed in the report, our conclusion is based
partly on the research conducted by George Washington University and
others showing that states have frequently not acted on the
opportunities that managed care presents to improve these services. 
Also as indicated in the report, it rests on information regarding
the effect managed care is having on how health departments and other
providers ensure that children who have elevated blood lead levels
receive needed follow-up services.  In considering HHS' comments, we
have modified the report to distinguish between opportunities that
are not yet acted upon and challenges faced by changing roles in the
delivery.  HHS also suggested, and we concurred, that the title of
the report should be modified to avoid the implication that CDC was
the report's main focus in reaching at-risk children. 

In regard to our recommendation that HHS develop better data on the
prevalence of lead poisoning in particular geographic locations, HHS
agreed that better prevalence data would be valuable.  However, HHS
also raised concerns about how this could be done, expressing concern
about the use of the NHANES for this purpose and citing instead
planned improvements to its surveillance system to ensure that
consistent data are collected.  We recognize the limitations of the
NHANES for assessing prevalence within local areas and did not intend
to suggest that it be used to assess local prevalence levels.  We
have modified our report accordingly.  We continue to believe that
until surveillance data can be shown to be reliable for particular
states or areas, grantees should be required to commit to periodic
surveys such as focal surveys of high-risk or other areas to gain
data for areas of concern (suggested as an option by HHS in its
comments). 

HHS also agreed that better information on screening rates within
federal health care programs is needed.  HHS pointed out several
reasons why developing screening rate information is problematic,
including additional administrative burdens on state Medicaid
agencies, but indicated that it is committed to working with its
stakeholders to develop and improve data collection.  HHS indicated
that it would initiate appropriate actions to respond to the parts of
our recommendation related to improving health center oversight and
establishing a waiver process from universal screening requirements
for states that can demonstrate low-prevalence communities. 

HHS agreed with our remaining three recommendations concerning
improving managed care contracts, reimbursement for services, and
integration with other federal programs.  In this regard, HHS cited
several specific actions it had taken or planned to take. 
Specifically: 

  -- CDC will continue to further develop, and HCFA will encourage
     states to use, model Medicaid managed care contract language to
     help ensure that high-risk children are screened and receive
     appropriate timely follow-up services. 

  -- HCFA will clarify its policy to the states on requirements that
     all appropriate treatment coverable under Medicaid should be
     provided to children who have elevated blood lead levels. 

  -- HHS has recently rechartered its CDC Advisory Committee on
     Childhood Lead Poisoning Prevention to include representatives
     from HCFA and HRSA, with working groups directed at addressing a
     number of issues in our report. 

Because the report discusses the role of WIC in lead screening, we
provided a copy of a draft of the report to USDA program officials
for review.  In commenting on the draft, the Associate Deputy for
Special Nutrition Programs noted that although WIC does not have a
specific legislative mandate for lead screening, it often conducted
the lead screening test in conjunction with required anemia testing
until CDC revised the protocols for measuring blood lead levels
(calling for more sensitive and significantly more costly procedures
than were used routinely in WIC).  The Associate Deputy stated that
although WIC remains committed to lead screening, it is not funded
for blood testing beyond the general scope of an anemia test.  The
Associate Deputy also said that if new technology and protocols are
developed that could permit lead screening without further
appreciable cost or time beyond which WIC usually devotes to anemia
screening, USDA would be pleased to work with CDC to determine the
feasibility of using them in WIC clinics.  USDA provided us with
technical comments that we incorporated as appropriate. 


METHODOLOGY AND RESULTS OF NHANES
DATA ANALYSIS
=========================================================== Appendix I

The National Health and Nutrition Examination Survey (NHANES),
conducted multiple times since 1960 by the National Center for Health
Statistics of the Centers for Disease Control and Prevention (CDC),
is designed to provide national estimates of the health and nutrition
status of the noninstitutionalized civilian population of the United
States aged 2 months and older.  Our analysis was based on the NHANES
data gathered during NHANES III, Phase 2, which was conducted from
October 1991 through September 1994 and represents the most current
information available.\77 Details of the survey design,
questionnaires, and examination components are published in the
NHANES III Plan and Operation reference manual.\78


--------------------
\77 The NHANES III survey had five goals:  (1) estimate the national
prevalence of selected diseases and risk factors, (2) estimate
national population reference distributions of selected health
characteristics, (3) document and investigate reasons for long-term
trends in selected diseases and risk factors, (4) contribute to an
understanding of disease origins and causes, and (5) investigate the
natural history of selected diseases. 

\78 National Center for Health Statistics, "Plan and Operation of the
Third National Health and Nutrition Examination Survey, 1988-94,"
Vital Health Statistics, Vol.  1, No.  32 (1994). 


   THE NHANES SAMPLING PROCESS
--------------------------------------------------------- Appendix I:1

The NHANES sample selection process, along with the weighing of
participants, is designed to ensure that the sample is nationally
representative of the U.S.  civilian noninstitutionalized population
2 months of age and over.  The selection of persons to participate in
NHANES had four steps.  First, the 13 largest counties were selected
automatically and 68 other counties were selected randomly, yielding
a total sample of 81 counties.  Second, geographic areas were
randomly selected within those counties.  Third, households and
certain other types of group quarters (such as dormitories) were
selected within those areas to identify potential participants.\79
Fourth, specific individuals in selected households were identified
on the basis of demographic characteristics.  The National Center for
Health Statistics has published the details of the survey design and
weighing methods.\80


--------------------
\79 NHANES III oversampled selected subpopulations to increase the
reliability of estimates.  These subpopulations were children aged 2
months through 5 years, blacks, Mexican Americans, and persons 60
years old or older. 

\80 "Weighing and Estimation Methodology Executive Summary," National
Health and Nutrition Examination Survey III (Rockville, Md.:  Westat,
Inc., 1996). 


   THE VARIABLES AND DEFINITIONS
   WE USED
--------------------------------------------------------- Appendix I:2

Persons participating in NHANES were interviewed extensively and
given a thorough physical examination in which a blood sample was
taken.  Data collected from the interviews, physical examinations,
and blood samples varied with the participants' age.  For our
analysis, we used the blood lead levels derived from the blood
samples for children aged 1 through 5.  We also used specific
information gathered during the interviews: 

  -- health insurance status, including Medicaid status;

  -- household income;

  -- family participation in the Special Supplemental Nutrition
     Program for Women, Infants, and Children (WIC); and

  -- previous tests for blood lead. 

Of the 15,427 persons examined in NHANES III, Phase 2, the survey
results for 2,350 children aged 1 through 5 years contained data on
blood lead levels, health insurance status, WIC participation, and
history of blood lead screenings.\81 We excluded from our analysis
some children who may be eligible for federal health care programs in
order to present conservative estimates of the prevalence of elevated
blood lead levels.  We excluded children whose income, insurance
status, or WIC participation was unknown. 

The variables and population estimates that we selected were
consistent with those CDC used to estimate the prevalence of elevated
blood lead levels among the population at large.  CDC defined
low-income persons as persons whose household income was 130 percent
of the federally defined poverty level or less and old housing as
housing built before 1946.\82


--------------------
\81 In some instances, the NHANES survey had information on some of
these questions but not on others.  When we used those questions in
our analysis, we excluded the children whose survey results were
missing. 

\82 Our definition of the low-income population was consistent with
CDC's but differed from that used by the Health Resources and
Services Administration (HRSA).  HRSA targets low-income populations
whose income is 200 percent of the poverty level or less.  We used
CDC's more conservative definition of low income in order to maintain
consistency with CDC's published reports on blood lead levels. 


   DATA RELIABILITY
--------------------------------------------------------- Appendix I:3

We reviewed the NHANES design, data reliability checks, and reporting
guidelines before using its data.  We also compared the
NHANES-computed estimates with Bureau of the Census population
estimates, reports on the Medicaid population by the Health Care
Financing Administration (HCFA), and Department of Agriculture (USDA)
estimates on the WIC population.  NHANES estimates for the number of
children receiving Medicaid, low income and uninsured, or
participating in WIC were generally consistent with estimates
published by HCFA, the Bureau of the Census, and USDA.\83 On the
basis of these reviews and comparisons, we concluded that the NHANES
data were sufficiently reliable to meet our objectives. 


--------------------
\83 The NHANES III, Phase 2, estimate for children in Medicaid aged 1
through 5 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 NHANES III, Phase 2, estimate for the number of
low-income children aged 1 through 5 who did not have health
insurance while participating in NHANES was 1,086,000.  The Bureau of
the Census 1993 estimate for the number of poor children aged 1
through 5 who did not have health insurance was 1,224,000.  The
NHANES III, Phase 2, estimate for children in WIC aged 1 through 4
years between 1991 and 1994 was 3,891,000.  USDA's estimate for the
number of children aged 1 through 4 in WIC as of April 1994 was
3,465,000.  An undetermined portion of the difference between the
NHANES and USDA estimates may stem from the nature of the WIC
participation question in the NHANES survey, which requested
information on the participant's status in the past month.  The USDA
estimate does fall within the 95-percent confidence interval for the
NHANES estimate. 


   ANALYSIS RESULTS
--------------------------------------------------------- Appendix I:4

The tables in this appendix show the estimates and their confidence
intervals from the NHANES data.  There is a 5-percent chance that the
actual number is outside these limits.\84 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 remain substantial. 

A small number of the means and confidence intervals we present vary
slightly from those we presented in our previous reports because of
slight changes in estimation techniques and methods as suggested by a
National Center for Health Statistics official.\85



                         Table I.1
          
            Estimated Number of Children Aged 1
                         Through 5

                                      Estimate
                          --------------------------------
                  Sample                 Lower       Upper
                    size      Mean       limit       limit
------------  ----------  --------  ----------  ----------
All                2,744  20,183,0  16,895,000  23,472,000
 children\a                   00\b
Children in          984  6,275,00   5,484,000   7,066,000
 Medicaid                        0
Low-income           261  1,086,00     908,000   1,263,000
 uninsured                       0
 children
\Children in         678  3,891,00   3,314,000   4,469,000
 WIC\c                           0
Other              1,014  11,947,0  11,119,000  12,774,000
 children\d                     00
----------------------------------------------------------
\a The sample analyzed was for all children regardless of whether
federal health care program status and blood lead results were known. 
For other samples we analyzed, we excluded children whose survey
results were missing responses to questions used in our analysis. 

\b CDC weighted the NHANES sample to approximate the Bureau of Census
1993 undercount-adjusted Current Population Survey. 

\c Children participating in WIC may also be participating in the
Medicaid program or may have low incomes and no health insurance. 
These figures are for ages 1 through 4, since WIC is for children
through age 4 only. 

\d Children who had health insurance and were not in Medicaid or WIC. 



                         Table I.2
          
            Estimated Number of Children Aged 1
           Through 5 Who Had Elevated Blood Lead
                           Levels

                                      Estimate
                          --------------------------------
                  Sample                 Lower       Upper
                    size      Mean       limit       limit
------------  ----------  --------  ----------  ----------
All children       2,386   890,000     557,000   1,223,000
Children in          984   535,000     254,000     815,000
 Medicaid\a
Low-income           261    67,000      \1,000     145,000
 uninsured
 children\a
Children in          678   452,000     262,000     642,000
 WIC\a
Other              1,014   202,000     107,000     297,000
 children
----------------------------------------------------------
Note:  CDC defines elevated blood lead levels as 10 g/dl or
higher. 

\a Numbers may not add up because children can be eligible for more
than one federal health program. 



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

                                      Estimate
                          --------------------------------
                  Sample                 Lower       Upper
                    size      Mean       limit       limit
------------  ----------  --------  ----------  ----------
All children       2,350  2,319,00   1,750,000   2,888,000
                                 0
Children in          966  1,183,00     862,000   1,504,000
 Medicaid\a                      0
Low-income           260   182,000     \83,000     281,000
 uninsured
 children\a
Children in          669   682,000     434,000     930,000
 WIC\a
Other                999   868,000     583,000   1,152,000
 children
----------------------------------------------------------
Note:  CDC defines elevated blood lead levels as 10 g/dl or
higher. 

\a Numbers may not add up because children can be eligible for more
than one federal health program. 



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

                                      Estimate
                          --------------------------------
                  Sample                 Lower       Upper
                    size      Mean       limit       limit
------------  ----------  --------  ----------  ----------
All children         145   557,000     455,000     659,000
Children in           95   347,000     266,000     427,000
 Medicaid\a
Low-income            12    19,000       1,000      36,000
 uninsured
 children\a
Children in           68   301,000     223,000     378,000
 WIC\a
Other                 27   120,000      55,000     186,000
 children
----------------------------------------------------------
Note:  CDC defines elevated blood lead levels as 10 g/dl or
higher. 

\a Numbers may not add up because children can be eligible for more
than one federal health program. 


--------------------
\84 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. 

\85 Following a suggestion from a National Center for Health
Statistics official, we used only the weight for children older than
1 who were examined away from home (only children who were younger
than 1 year old were examined at home). 


METHODOLOGY AND RESULTS OF
MEDICAID BILLING DATA ANALYSIS
========================================================== Appendix II

To assess available data on state Medicaid screening for children
covered by fee-for-service arrangements, we analyzed HCFA's State
Medicaid Research Files.  This database provides summarized
information on Medicaid eligibility, claims, and utilization for
states that participate in the Medicaid Statistical Information
System.  To facilitate research, HCFA has adjusted and reformatted
the data and added service and eligibility codes.  The data are
arranged in five separate research files:  Drug Claims, Inpatient
Claims, Long-Term Care Claims, Other Ambulatory Claims, and Person
Summary.  Claims information is unavailable for children in Medicaid
managed care arrangements, and reliable data on health care services
provided to these children were not available at the time of our
review. 


   ANALYSIS METHODOLOGY
-------------------------------------------------------- Appendix II:1

We used the Person Summary and the Other Ambulatory Claims files to
determine the percentage of children who had received a blood lead
test within 6 months (on either side) of their first or second
birthday.  The Person Summary file contains characteristics such as
birthday and dates of coverage for each person covered by Medicaid
during the year.  The Other Ambulatory Claims file contains records
for medical services received. 

Our analysis was limited to 1994 and 1995 data from 15 states, all
states for which complete 1994 and 1995 data were available.  We
looked only at those 2 years because they were the latest years for
which the State Medicaid Research Files data were available after
HCFA's requirement for universal Medicaid screening went into effect
in 1992.  Thirty-one states did not provide data for 1994 and 1995. 
We dropped two states because we were able to access only part of the
information we needed.  We dropped three states because we were
informed that at least one government laboratory did not bill
Medicaid by individual children, making it impossible to determine
from the billing data whether the children in those states had been
given blood lead tests. 

We performed separate analyses for children at ages 1 and 2.  To
provide conservative estimates of children not screened, we limited
our analysis to children for whom the data indicated that they had an
opportunity to receive a blood lead test that Medicaid paid for. 
Specifically, we limited our analysis to a cohort of children who (1)
were in Medicaid for 6 months before and after their birthday, (2)
had their first or second birthday between July 1994 and June 1995,
(3) had made at least one visit to a Medicaid provider, (4) had no
evidence of ever having been in managed care, and (5) had no evidence
of having had private health insurance before 19 months for
1-year-olds and 31 months for 2-year-olds. 

To determine whether a child received a blood lead test, we reviewed
outpatient claims for evidence of a laboratory procedure for blood
lead analysis because that procedure is generally billed under a
unique code and is easily identified.  Provider services for drawing
the blood sample, in contrast, could be bundled with other outpatient
services and may not be readily identified.  We credited a child as
having received a blood lead test if a claim was made within 6 months
of the child's first or second birthday.  We checked with each
participating state Medicaid program the particular coding and
process they used for recording the state's data. 

Other than these quality control checks, we did not independently
verify the data in the State Medicaid Research Files because (1)
HCFA's process for modifying the data includes quality control phases
in which the data are analyzed with a number of statistical tools and
crosswalks and (2) the data originated at the state level and the
benefit of tracking them back to their source would not have
outweighed the considerable cost and staff resources that this would
have entailed.  These data represent the most current and complete
data available on state-level billing within Medicaid fee-for-service
programs. 


   ANALYSIS RESULTS
-------------------------------------------------------- Appendix II:2

Our analysis shows that the rate at which 15 states' Medicaid
fee-for-service programs provided blood lead screening for 1- and
2-year-old children in Medicaid was about 21 percent during 1994 and
1995.  Rates for the 15 states ranged from less than 1 percent in
Washington to about 46 percent in Alabama.\86 Table II.1 gives
details of our results. 



                                        Table II.1
                         
                            Billing Rates of 15 State Medicaid
                         Programs for Laboratory Tests for Blood
                                  Lead Levels in 1994-95

                           Age 1                   Age 2                   Total
                   ----------------------  ----------------------  ----------------------
                                   Percen                  Percen                  Percen
                           Number       t          Number       t          Number       t
                   Cohort  screen  screen  Cohort  screen  screen  Cohort  screen  screen
State                size      ed      ed    size      ed      ed    size      ed      ed
-----------------  ------  ------  ------  ------  ------  ------  ------  ------  ------
Alabama            16,800   8,331      50  15,073   6,210      41  31,873  14,541      46
Arkansas            5,200   1,556      30   5,606   2,001      36  10,806   3,557      33
Colorado            7,241     881      12   6,150     415       7  13,391   1,296      10
Delaware            1,600     612      38   1,495     324      22   3,095     936      30
Florida\a          14,275   2,658      19  12,570   1,884      15  26,845   4,542      17
Kentucky           14,230   1,340       9  13,534   1,122       8  27,764   2,462       9
Mississippi        12,134   3,615      30  11,330   3,019      27  23,464   6,634      28
Missouri           20,947   4,216      20  19,329   3,246      17  40,276   7,462      19
Montana             1,809      44       2   1,762      61       3   3,571     105       3
New Jersey         14,585   6,144      42  14,759   5,424      37  29,344  11,568      39
North Dakota        1,268      34       3   1,312      41       3   2,580      75       3
Pennsylvania\a     16,729   2,245      13  14,529   1,717      12  31,258   3,962      13
Vermont             1,267     120       9   1,309      78       6   2,576     198       8
Washington         17,331      61     0.4  15,251      22     0.1  32,582      83     0.3
Wisconsin           4,120   1,410      34   5,418   1,610      30   9,538   3,020      32
=========================================================================================
Total              149,53  33,272      22  139,42  27,174      19  288,96  60,440      21
                        6                       7                       3
-----------------------------------------------------------------------------------------
\a Excludes data from Pinellas County, Florida, and Philadelphia
County, Pennsylvania, because laboratories in these counties do not
send individual billing data to HCFA. 


--------------------
\86 We contacted both states' lead registries to determine whether
these rates were consistent with the data they collected.  Both
health departments confirmed that these screening rates were
consistent with those reported in their states.  For example, less
than 1 percent of all children in Washington were screened for lead
poisoning in 1996. 


METHODOLOGY FOR OUR QUESTIONNAIRE
TO MEDICAID DIRECTORS
========================================================= Appendix III

We developed the questionnaire we sent to Medicaid directors to
identify state Medicaid policies and practices for screening and
treating children for elevated blood lead levels.  We sought
information on a number of items including (1) the program's coverage
of services for treating children with elevated blood lead levels,
(2) the number of children in Medicaid aged 5 and younger in managed
care arrangements, (3) the availability of data on screening and the
prevalence of elevated blood lead levels in children in Medicaid, (4)
monitoring mechanisms for ensuring that children in Medicaid are
screened and treated once they have been identified as having
elevated blood lead levels, and (5) documentation of EPSDT policies
and other relevant information, such as formal agreements or
memorandums of understandings with other agencies regarding screening
or treatment of children for elevated blood lead levels. 

We pretested the questionnaire with officials from several Medicaid
agencies and obtained and incorporated comments from several
reviewers knowledgeable about Medicaid or lead poisoning prevention
programs.  These reviewers included officials from HCFA, CDC's Lead
Poisoning Prevention Branch, and representatives of the American
Public Welfare Association, the Academy of State Health Policy, and
the Alliance to End Childhood Lead Poisoning. 

We sent the final questionnaire to the Medicaid directors in 50
states and the District of Columbia in November 1997.  All Medicaid
directors or their representatives responded. 


FEDERAL GUIDANCE AND POLICIES FOR
SCREENING AND TREATING CHILDREN
FOR ELEVATED BLOOD LEAD LEVELS
========================================================== Appendix IV

A number of federal health agencies play critical roles in providing
national lead poisoning prevention guidance and policies.  CDC issues
recommendations for screening young children for elevated blood lead
levels.  HCFA, which administers Medicaid, establishes requirements
for the provision of screening services for children covered by
Medicaid as part of its EPSDT program.  HRSA, which provides grants
to health centers to provide health services in medically underserved
areas--including services to children in Medicaid and uninsured
children--establishes policies for children's health care services. 
Table IV.1 shows the specific guidelines and policies for screening
established by these federal agencies. 



                         Table IV.1
          
          Federal Guidance and Policies for Blood
                       Lead Screening

                                      Screening
                            ------------------------------
            Risk
            assessment      High risk       Low risk
----------  --------------  --------------  --------------
1991 CDC    Assess the      At a minimum,   At a minimum,
guidelines  child's risk    an initial      an initial
            for high-dose   test at 6       test at 12
            exposure at 6   months and      months and
            months and      every 6 months  rescreening at
            each regular    thereafter      24 months if
            office visit    (until two      possible.
            thereafter.     consecutive
                            tests are
                            lower than 10
                            g/dl
                            or three are
                            less than 15
                            g/
                            dl, when
                            testing can be
                            reduced to
                            annually). At
                            36-72 months,
                            any child at
                            high risk not
                            previously
                            tested should
                            be tested.

1997 CDC    CDC recommends
guidelines  that state
            health
            officials
            develop
            screening
            guidelines. In
            their absence,
            CDC recommends
            screening all
            children at 1
            and 2 years
            and 36-72
            months who
            have not been
            previously
            screened. CDC
            recommends
            that, in
            general,
            children who
            receive
            Medicaid
            benefits
            should be
            screened
            unless
            reliable,
            representative
            blood lead
            level data
            demonstrate
            the absence of
            lead exposure.

1994 HRSA   Assessment of   An initial      An initial
Bureau of   risk should be  test at 6       test at 12
Primary     a part of each  months or when  months. Each
Health      well-child      the child is    center should
Care        visit and       determined to   develop a
policy for  other           be at high      protocol for
health      pediatric       risk. Each      anticipatory
centers     visits as       center should   guidance, risk
            appropriate,    develop a       assessment,
            from 6 months   protocol for    lead testing,
            to 6 years.     anticipatory    and follow-up
                            guidance, risk  of abnormal
                            assessment,     results.
                            lead testing,
                            and follow-up
                            of abnormal
                            results.

1993        Beginning at 6  A test is       A test at 12
Medicaid    months and at   required when   and 24 months.
manual      each visit      a child is      A child
            thereafter,     identified as   between 24 and
            the provider    being at high   72 months who
            must assess     risk,           has not been
            the child's     beginning at 6  tested must be
            risk for        months. A test  tested
            exposure,       is required at  immediately.
            asking          every visit
            specified       prescribed in
            questions at a  the EPSDT
            minimum.        periodicity
                            schedule
                            through 72
                            months, unless
                            the child has
                            already
                            received a
                            test within
                            the last 6
                            months of the
                            periodic
                            visit.

1998        No risk         A screening     A screening
Medicaid    assessment is   test must be    test must be
manual      required.       provided at 12  provided at 12
                            and 24 months.  and 24 months.
                            A child         A child
                            between 36 and  between 36 and
                            72 months who   72 months who
                            has not         has not
                            received a      received a
                            screening       screening
                            blood lead      blood lead
                            test must be    test must be
                            screened.       screened.
----------------------------------------------------------
Ensuring that a child who has an elevated blood lead level receives
the services needed to lower the level involves many organizations
other than the child's health care provider.  The CDC guidelines
state that comprehensive services for a lead-poisoned child are best
provided by a team that includes the health care provider, care
coordinator, community-health nurse or nurse adviser, environmental
specialist, social services liaison, and housing specialist.  Drug
remedies are generally not recommended except in chelation therapy
for children who have blood lead levels of 45 g/dl or
higher.\87 Table IV.2 summarizes federal guidelines and policies for
retesting to ensure that blood lead levels decline. 



                               Table IV.2
                
                Federal Guidance and Policies for Blood
                             Lead Treatment

                  Recommendation
----------------  ----------------------------------------------------
1991 CDC          At 10 g/dl or higher, retesting at least at
guidelines        3-or 4-month intervals until blood lead levels have
                  declined. At 20 g/dl or higher, CDC
                  recommends clinical management--clinical evaluation
                  for complications of lead poisoning, family lead
                  education and referrals, chelation therapy if
                  appropriate, and follow-up testing at appropriate
                  intervals. At both levels, children should receive
                  environmental investigation, coordination of care,
                  and lead-hazard control services.

1997 CDC          At 10 g/dl or higher, retesting at 2-to 3-
guidelines        month intervals until blood lead levels have
                  declined, lead hazards have been removed, and there
                  is no new exposure. At or above 20 g/dl,
                  retesting should be even more frequent.
                  Recommendations for clinical management are the same
                  as in the 1991 guidelines.

1994 HRSA Bureau  Each center should develop a protocol for
of Primary        anticipatory guidance, risk assessment, lead
Health Care       testing, and follow-up of abnormal results. All
policy for        follow-up should be done in accordance with CDC
health centers    guidelines.

1993 Medicaid     At 10 g/dl or higher, providers are to use
manual            their professional judgment with reference to CDC
                  guidelines covering patient management and
                  treatment, including follow-up blood tests and
                  investigations to determine the source of lead when
                  indicated.\a

1998 Medicaid     Adds to the 1993 manual that determining the source
manual            of lead may be reimbursable by Medicaid under
                  certain circumstances but that reimbursement is
                  limited to a health professional's time and
                  activities during an on-site investigation of a
                  child's home or primary residence. The child must be
                  diagnosed as having an elevated blood lead level.
                  Medicaid reimbursement is not available for any
                  testing of substances such as water and paint that
                  are sent to a laboratory for analysis.
----------------------------------------------------------------------
\a The manual is silent on expectations for covering treatment
services but policy memorandums to regional offices state that
investigations are integral to management and treatment and may be
reimbursable under Medicaid as a rehabilitative services benefit. 


--------------------
\87 Ongoing research by the National Institute of Environmental
Health Sciences is assessing the treatment of children exposed to
lead--specifically, home cleanup, nutritional supplementation, and
chelation therapy for children whose blood lead levels are between 20
and 44 g/dl. 


METHODOLOGY AND RESULTS OF
SCREENING OF CHILDREN AT HEALTH
CENTERS
=========================================================== Appendix V


   SAMPLING METHODOLOGY
--------------------------------------------------------- Appendix V:1

To better understand the extent to which health centers screened
children for elevated blood lead levels, we visited several high-risk
centers and reviewed a sample of medical records.  We considered a
center to be at high risk if it was in an area with a large number of
old (pre-1950) homes and saw a large number of children who were
enrolled in Medicaid.  We used 1990 census data to determine the
number of old homes in the same zip code as a health center.\88 We
used HRSA's 1996 Unified Data System Report data to determine the
number of children who were younger than 5 and enrolled in Medicaid
and seen at the center.  For each of 10 HHS regions, we weighted
these two parameters and ranked the health centers by their overall
score.  We then judgmentally selected one center from the five
highest-risk centers in regions 1, 2, 3, 4, 6, 9, and 10.  We limited
our review to facilities in these seven regions because of time and
resource constraints.  We chose these locations to ensure that our
samples were geographically diverse. 

At six of the seven centers, we looked at the medical records for a
random sample of about 15 children who were born between January 1,
1994, and June 30, 1995, and seen in 1996.  These children were 1 or
2 years old in 1996.  In considering whether children were
appropriately screened, we presumed that as their regular provider,
the health centers should have tested them.  For this reason, we
reviewed only medical records for children who had been seen at least
once for a well-child (or preventive health care) visit or at least
three times for acute care visits.  We did not review any medical
files at the community health center we visited in Everett,
Washington.  Officials there told us that they did not have records
of screening any children in 1996 and had screened only three
children in 1997.  We confirmed with the Washington health
department's lead registry that this center had screened three
children during 1993-98. 


--------------------
\88 Wessex, Inc., publishes Pro/Filer, a data software combination
product that allows users to access demographics from the 1990 U.S. 
census.  We used pre-1950 housing age data because that was the
closest breakdown to the pre-1946 cutoff used in our NHANES analysis. 


   ANALYSIS METHODOLOGY
--------------------------------------------------------- Appendix V:2

At each health center, we reviewed health center protocols for
screening children for elevated blood lead levels, when available,
and discussed the protocols with the health center's medical director
and other staff.  We discussed with health center management and
clinical officials the barriers they faced in ensuring that children
seen at the health center were screened. 

From each medical record we reviewed, we recorded data on each visit
to the health center, including all dates representing screening
blood tests.  We considered that a child had been screened if the
medical record showed evidence of one blood lead test at some time in
the child's history with the health center.  We considered a screen
to be in line with CDC recommendations and HCFA policy for screening
at 1 year and 2 years if the child was screened within 6 months of
his or her first and second birthday.  If a child younger than 6
months was screened, we also considered this to be a screen at 1 year
of age.  We considered a screen to be on time if a child was screened
at age 1 year and 2 (when presenting for care at those ages).  We
recorded evidence of a provider's order for a laboratory test as well
as evidence of whether the laboratory test was actually performed in
order to assess whether ordered tests were completed. 

We conducted our medical records reviews at health centers from
October 1997 through March 1998 in accordance with generally accepted
government auditing standards. 


   ANALYSIS RESULTS
--------------------------------------------------------- Appendix V:3

Table IV.1 shows the results of our analysis.  While we generally
reviewed about 15 files at each location, at one we reviewed only 14
files and at another we reviewed 16 files.  This slight variance in
the sample size has no effect on the analysis because we are not
projecting the results to a larger universe. 



                         Table V.1
          
          Screening for 1-and 2-Year-Old Children
              at Seven Health Centers in 1996

                                  Percen  Percen
                          Percen       t       t
                          t ever  screen  screen   Percent
Health center     Sample  screen   ed at   ed at  screened
site               cases      ed   age 1   age 2   on time
----------------  ------  ------  ------  ------  --------
Atlanta, Ga.          14      64      42      60        38
Brooklyn, N.Y.        15      93      80      64        60
Everett, Wash.         0       0       0       0         0
New Bedford,          15     100     100      85        85
 Mass.
Philadelphia,         15     100     100      85        87
 Pa.
San Antonio,          16      50      62      21        27
 Tex.
Watsonville,          15      80      46      54        27
 Calif.
----------------------------------------------------------

METHODOLOGY AND RESULTS FOR
FOLLOW-UP TESTING OF CHILDREN WITH
ELEVATED BLOOD LEAD LEVELS SEEN AT
HEALTH CENTERS
========================================================== Appendix VI


   SAMPLING METHODOLOGY
-------------------------------------------------------- Appendix VI:1

To better understand the extent to which health centers provided
follow-up testing to children they found to have elevated blood lead
levels, we visited several high-risk health centers and reviewed a
sample of the medical records of these children.  We considered a
center to be at high risk if it was located in an area with a large
number of old (pre-1950) homes and saw a large number of children who
were enrolled in Medicaid.  We used 1990 census data to determine the
number of old homes in the same zip code as a health center.\89 We
used HRSA's 1996 Unified Data System Report data to determine the
number of children who were younger than 5 and enrolled in Medicaid
and seen at the center.  For each of the 10 HHS regions, we weighted
these two parameters and ranked the health centers by their overall
score.  We then judgmentally selected one center from the five
highest-risk centers in regions 1, 2, 3, 4, 6, 9, and 10.  We limited
our review to facilities in these seven regions because of time and
resource constraints.  We chose these locations to ensure that our
samples were geographically diverse. 

At six of the seven centers, we looked at medical records for a
random sample of about 15 children who were found to have blood lead
levels of 10 g/dl or higher in 1996.  We did not review any
medical records at the health center in Everett, Washington. 
Officials there told us that they did not have records of screening
any children in 1996 and, therefore, had not identified any children
with elevated blood lead levels. 


--------------------
\89 See the preceding footnote. 


   ANALYSIS METHODOLOGY
-------------------------------------------------------- Appendix VI:2

At each health center, we reviewed health center protocols for
screening children for elevated blood lead levels, when available,
and discussed the protocols with the health center's medical director
and other staff.  We discussed with health center management and
clinical officials the barriers they faced in ensuring that children
seen at the health center received follow-up testing and other
services needed to lower their levels. 

From each medical record we reviewed, we recorded data on each visit
to the health center.  We recorded all dates where records showed
that a child's provider ordered a follow-up test, whether laboratory
test results were present showing that the ordered test had been
completed, and the blood lead levels.  For each blood lead test
result at 10 g/dl or higher in the child's medical record
for 1996, we determined the time until a follow-up test was done and
the number of missed opportunities to follow up (when the child was
given care but was not provided a follow-up blood lead test).  For
analysis purposes, we considered each blood test subsequent to one
finding an elevated blood lead level to be a follow-up test,
regardless of the time between tests. 

For each elevated blood lead level, we determined whether a follow-up
test was done on time, using criteria based on CDC's 1991 lead
screening and treatment guidelines.\90 The specific criteria we used
follow: 

1.  For children younger than 3, a follow-up should be done in 3 to 4
months (120 days or less). 

2.  For children 3 or older with a blood lead level equal to or
greater than 15 g/dl, a follow-up should be done in 3 to 4
months. 

3.  For children 3 or older with a blood lead level less than 15
g/dl but a former blood lead level equal to or greater than
15 g/dl, a follow-up should be done in 12 months. 

4.  Children aged 3 or older who have never had a blood lead level
equal to or greater than 15 g/dl do not need a follow-up. 

We defined a missed opportunity as any visit to the center 90 days
after the elevated blood lead level was found for children meeting
criteria 1 and 2 above or 270 days later for children meeting
criterion 3.  Children with no follow-up and no missed opportunities
were children who did not return to the center. 

We conducted our medical records reviews at health centers from
October 1997 through March 1998 in accordance with generally accepted
government auditing standards. 


--------------------
\90 CDC's 1997 guidelines shortened the recommended time between
follow-up tests. 


   ANALYSIS RESULTS
-------------------------------------------------------- Appendix VI:3

Although our samples were randomly selected, it is not possible to
project from our analysis.  First, the sites were judgmentally
selected from high-risk locations and thus are not representative of
all health centers.  Second, our analysis was not weighted to ensure
that the samples reflected the population of children visiting the
health centers.  Table VI.1 shows our results. 



                         Table VI.1
          
           Follow-Up Testing Provided to Children
           Whose Elevated Blood Lead Levels Were
           Identified by Seven Health Centers in
                            1996

                                         Follow-up not on
                                               time
                                        ------------------
                              Elevated
                                 blood
                      Sample     level
Health center site     cases     tests    Number   Percent
------------------  --------  --------  --------  --------
Atlanta, Ga.              26        29        19        66
Brooklyn, N.Y.            15        27         5        19
Everett, Wash.             0         0         0         0
New Bedford, Mass.        19        35        19        54
Philadelphia, Pa.         15        28        11        39
San Antonio, Tex.         16        25        12        48
Watsonville,              11        14         4        29
 Calif.
----------------------------------------------------------

STATE REQUIREMENTS SUPPORTING CDC
GRANTEES' EFFORTS TO ENSURE THAT
CHILDREN ARE SCREENED AND PROVIDED
FOLLOW-UP SERVICES
========================================================= Appendix VII

In 1988, the Congress passed section 317A of the Public Health
Service Act, authorizing CDC to make grants aimed at preventing
childhood lead poisoning.  The legislation established program goals
that included screening infants and children for lead and follow-up
referrals for treatment and environmental intervention for those
found to have elevated blood lead levels.  Two types of grants are
available:  Childhood Lead Poisoning Prevention grants and Childhood
Blood Lead Surveillance grants.  The majority of CDC's grant funding
for childhood lead poisoning prevention--totaling $27 million in
fiscal year 1998--is directed toward prevention grants to (1) ensure
that children are screened for lead poisoning, (2) ensure that
children who have elevated blood lead levels receive timely and
appropriate follow-up, (3) provide education about childhood lead
poisoning and prevention, and (4) as of the fiscal year 1998 grant
cycle, capture data on screening and follow-up activities for
surveillance purposes.  The surveillance grants are aimed as of the
fiscal year 1998 grant cycle at developing statewide surveillance
systems for capturing data on screening and follow-up activities and
monitoring progress.  Both grant types require a commitment to
screening and reporting on elevated blood lead levels.  In 1998, 43
state and local health departments received prevention grants and 10
received surveillance grants. 


   METHODOLOGY
------------------------------------------------------- Appendix VII:1

To determine what CDC-supported programs were doing to ensure that
children were screened for elevated blood lead levels and, once
identified, treated appropriately, we met with officials from six
state and local Childhood Lead Poisoning Prevention and Childhood
Blood Lead Surveillance programs.  The prevention programs were
managed by California and Massachusetts and New York and
Philadelphia, and the surveillance programs were run by Washington
and Texas.\91 We chose these programs because they were
geographically close to the health centers that we visited.  Although
we did not meet with officials from the Georgia program, which was
not receiving CDC grant funding at the time of our review, we did
discuss the program with an official on the telephone.  For each
program, we obtained the most recent CDC grant application; state
legislation or procedures addressing lead poisoning screening,
reporting, and follow-up requirements; quarterly reports to CDC;
available measures or estimates of screening and prevalence rates;
and information about program activities. 


--------------------
\91 Philadelphia did not receive a CDC grant but received CDC funding
through a CDC grant to Pennsylvania. 


   STATE AND LOCAL INFRASTRUCTURES
   FOR ENSURING SCREENING AND
   TREATMENT VARY WIDELY
------------------------------------------------------- Appendix VII:2

The legal infrastructure for lead poisoning prevention efforts at the
state and local levels can significantly affect the ability of health
departments to ensure the screening, reporting, and follow-up of
children who have elevated blood lead levels.  All the states and
cities we contacted had some type of requirement for laboratories to
report lead test results, but the reportable levels differed,
affecting the usefulness of the data for identifying screening rates
and areas with children at higher risk.  Two of the seven programs we
reviewed were in states that had requirements for screening, and
those programs reported higher screening rates than the others we
visited.  More than half of the programs we contacted were in states
lacking specific laws to enforce the abatement of identified lead
hazards. 


      BACKGROUND ON CDC'S 1997
      SCREENING RECOMMENDATIONS
----------------------------------------------------- Appendix VII:2.1

Before 1997, CDC recommended that virtually all children aged 1
through 5 be screened for elevated blood lead levels.  In November
1997, CDC acknowledged the generally low rates of screening and the
declining prevalence of elevated blood lead levels and recommended
that state public health officials develop statewide plans for
childhood blood lead screening.  CDC recommended that statewide plans
contain if necessary different recommendations for screening within
particular areas of a state and that targeted screening be based on
data that are representative of the populations within those
divisions.  CDC set the following criteria for the states to use in
evaluating the usefulness of blood lead level data and developing
targeted screening plans:  (1) laboratory data are available for
children who have been screened, are of good quality, and are
available for individual children; (2) demographic, socioeconomic,
and geographic data are available for individual children; (3)
screening data are representative of the pediatric population of the
jurisdiction and are available for a sample that is large enough to
allow a valid estimate of prevalence. 

Policies based on such data are ideal because, while CDC's most
recent estimate indicates that 4.4 percent of children aged 1 through
5 have elevated blood lead levels, their prevalence can vary
significantly depending on local conditions.  Lacking representative
prevalence data, states and localities must rely on other sources
such as census data to identify children who have universal risk
factors.  Such factors include living in older houses or in
low-income families, and a significant number of young children have
at least one risk factor. 


      PROVIDER SCREENING AND
      LABORATORY REPORTING
      REQUIREMENTS
----------------------------------------------------- Appendix VII:2.2

Some states require providers to screen children and have mechanisms
to ensure that screening occurs, such as requiring proof of screening
as a condition for enrolling in daycare or school.  CDC's 1998
assessment found that 3 of 20 states receiving CDC grants mandated
screening all children aged 6 or younger.  New York and
Massachusetts, two of the seven CDC-supported programs that we
contacted, had requirements that providers screen for blood lead
levels.  They also had the highest reported screening rates of the
programs we visited.\92 Table VII.1 details differences in state
screening and reporting policies and known or estimated screening and
prevalence rates. 

Many states and jurisdictions have laboratory reporting requirements
to ensure that blood lead test results are reported.  However, not
all require the reporting of all (elevated and nonelevated) blood
lead test results, limiting the usefulness of the data for targeting
screening and surveillance purposes.  Among the states and localities
we contacted, universal reporting--the reporting of all blood lead
level tests regardless of result--was required in Massachusetts, New
York, and Washington.  While Washington had universal reporting
requirements and could calculate screening rates, less than 1 percent
of the children there had been screened, preventing the state from
accurately determining local prevalence levels.  California, Georgia,
Pennsylvania, and Texas required that only blood lead levels above a
specific level be reported, hindering states and localities from
reliably calculating their screening rates and prevalence levels. 
Instead, they relied on estimating general screening rates for
population segments--for example, by reviewing Medicaid billing data. 

CDC-provided information also shows how the states' requirements
differ.  A 1998 CDC assessment of selected grantees' laboratory
reporting requirements found that, of 20 states contacted, 10 had
legal requirements for laboratories to report all blood lead test
results, 4 required reporting results of 10 g/dl or higher,
1 required reporting results of 11 g/dl or higher, 2
required reporting results of 15 g/dl or higher, 1 required
reporting results of 20 g/dl or higher, 1 required reporting
results of 25 g/dl or higher, and 1 had no reporting
requirements.\93



                        Table VII.1
          
           1996 Screening and Reporting Policies
              and Reported Screening Rates and
              Prevalence for Sites We Visited

                        Health
                        department  Level at
                        estimates   which
              Screenin  of          reporting   Reported
              g of      screening   is          prevalence
              certain   rates for   required    of
              children  children    by law      elevated
              required  aged 1      (  blood lead
Site          by law    through 5   g/dl)\a     levels
------------  --------  ----------  ----------  ----------
California    No\b      Unknown     25          Unknown
                        (estimated
                        22 percent
                        among
                        children
                        in
                        Medicaid
                        in 1994)

Georgia       No        Unknown     10          Unknown

Massachusett  Yes\c     54 percent  0           3.7
s                                               percent

New York\d    Yes\e     44 percent  0           5.46
                        for 1-and               percent in
                        2-year-                 1995
                        olds and
                        42 percent
                        for 3-to
                        5-year-
                        olds

Pennsylvania  No        Unknown     25\f        Unknown
\d                      (estimated
                        30 percent
                        in
                        Philadelph
                        ia)

Texas         No        Unknown     10          Unknown
                        (estimated
                        33 percent
                        among
                        children
                        in
                        Medicaid
                        and 11
                        percent
                        for all
                        children)

Washington    No        Less than   0           Unknown\g
                        1 percent
----------------------------------------------------------
\a California:  Cal.  Health and Safety Code, Sec.  124130 (Deering
1997); Georgia:  Rules of the Department of Human Resources, Ch. 
290-5-3; Massachusetts:  Mass.  Regs.  Code tit.  105,  460.070
(1995); New York:  N.Y.  Public Health, ch.  45.  article 13, title Y
 1370-e(3); Pennsylvania:  28 Pa.  Code,  27.4 (1993); Texas:  25
Tex.  Admin.  Code  37.334 (1998); Washington:  Wash.  Admin.  Code
 246-100-042 (1997).  The states verified these legal references in
November 1998. 

\b Pursuant to a settlement agreement in federal district court,
California adopted a blood lead screening protocol for its Child
Health and Disability Prevention program based on CDC guidelines. 
Under the protocol, eligible children are to be screened at 1 and 2
years or between 25 and 72 months if not already screened and
whenever a risk assessment identifies them as being at high risk. 

\c All children at approximately 1, 2, 3, and 4 years, with more
frequent screening for children determined to be at high risk for
lead poisoning after an assessment based on CDC guidelines.  Blood
lead screens are required for kindergarten enrollment. 

\d Screening and prevalence data for New York and Pennsylvania are
those reported for the cities of New York and Philadelphia. 

\e All children at around 1 and 2 years, with screening of older
children up to age 6 who are determined by a risk assessment to be at
high risk.  Blood lead screens are required for certified daycare and
preschool enrollment. 

\f According to city health officials, blood lead levels equal to or
higher than 15 g/dl are required to be reported in
Philadelphia. 

\g While reporting all blood lead test results is required, data are
not considered to be representative since less than 1 percent of
children have been screened. 


--------------------
\92 Although other states lacked reliable data on the screening
rates, most had estimated rates based on other available information. 

\93 CDC collected this information in its effort to report on state
lead surveillance activities. 


      REQUIREMENTS FOR ADDRESSING
      IDENTIFIED LEAD HAZARDS
----------------------------------------------------- Appendix VII:2.3

One barrier to screening that officials cited was the lack of
authority or resources to address the sources of blood lead level
conditions, often the lead hazards in housing.  The National
Conference of State Legislatures in 1997 compiled some information on
residential abatement standards by state and reported that of 31
states for which information was available, only 11 required
residential abatements.  We found major differences in the authority
of state and local officials to ensure that identified lead hazards
are addressed, as shown in table VII.2. 



                              Table VII.2
                
                Seven Sites' Requirements for Addressing
                        Lead Hazards in Housing

Site              Requirement
----------------  ----------------------------------------------------
California        Officials indicated that lead hazards could be
                  considered a "nuisance" under the Health and Safety
                  Code and that the health department could order an
                  abatement of such nuisances under penalty of law.\a

Georgia           No abatement laws.

Massachusetts     Responsible parties are required to abate lead
                  hazards. Residences occupied by children who have
                  blood lead levels of 25 g/dl or higher must
                  have environmental investigations. If an occupant
                  refuses admission, a search warrant may be obtained.
                  Owners of dwellings containing dangerous levels of
                  lead in accessible structural material are required
                  to obtain certification of full compliance or
                  interim control where children younger than 6 reside
                  or the owner receives an order to "delead." Owners
                  may be liable for all damages to children caused by
                  failure to comply with certain inspection and
                  abatement requirements.

New York City     Responsible parties can be ordered to do lead
                  abatement work.\b If owners or other persons having
                  legal responsibility fail to comply with an
                  abatement order within 5 days, the city may contract
                  for abatement at the owners' expense.\c

Philadelphia      Owners of residential property are required to
                  eliminate lead hazards caused by paint on threat of
                  having their rental licenses revoked.\d However,
                  since only about 30 percent of landlords are
                  licensed, according to city officials, such threats
                  are not very effective.

Texas             No abatement laws.

Washington        No abatement laws.
----------------------------------------------------------------------
\a We did not address the extent to which other states had similar
"nuisance" laws. 

\b Mass.  Gen.  Laws, ch.  111,  194, 199 (1994); Mass.  Regs. 
code tit.  105,  460.020, 460.100. 

\c N.Y.C.  Health Code,  173.13. 

\d Philadelphia Health Code,  6-403(5). 




(See figure in printed edition.)Appendix VIII
COMMENTS FROM HHS
========================================================= Appendix VII



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GAO CONTACTS AND STAFF
ACKNOWLEDGEMENTS
========================================================== Appendix IX

GAO CONTACTS

Frank Pasquier, Assistant Director (206) 287-4861
Katherine Iritani, Evaluator-in-Charge (206) 287-4820

STAFF ACKNOWLEDGMENTS

In addition to the persons named above, the following persons made
important contributions to this report:  Matthew Byer conducted the
Medicaid survey, Timothy Clouse analyzed the NHANES data, Evan Stoll,
Jr., analyzed Medicaid billing data and health center samples,
Patricia Yamane oversaw fieldwork at health centers and work related
to treatment issues, Stanley Stenersen guided the message development
and report writing, George Bogart served as attorney adviser, Susan
Lawes assisted with the Medicaid survey methodology, and Molly Laster
compiled information on state screening and reporting requirements. 
Marsha Lillie-Blanton provided technical assistance on this
assignment. 


*** End of document. ***