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Statement by
Ruben King-Shaw, Jr.
Deputy Administrator and Chief Operating Officer Centers for Medicare & Medicaid Services
on
Lead-based Paint Poisoning: Federal Responses
before the
Senate Committee on Banking, Housing, and Urban Affairs, Subcommittee on Housing and Transportation

June 5, 2002

Chairman Reed, Senator Allard, distinguished Subcommittee members, thank you for inviting me to this hearing today to discuss the Centers for Medicare & Medicaid Services' (CMS) efforts to address lead-based poisoning in children. Specifically, I would like to discuss CMS' role in providing screening and treatment for at-risk children. Despite dramatic reductions in blood-lead levels over the past 20 years, lead poisoning continues to be a significant health risk for young children, particularly those from low-income families or who live in older housing. I know that you, Chairman Reed, have a keen interest in this issue, and we recognize and appreciate your efforts and the work of this Subcommittee.

Although lead poisoning is a preventable condition, it remains a health concern for America's children. Administrator Scully and I share your concern regarding the very real dangers posed by lead poisoning, and I want to emphasize CMS' commitment to protecting the health and well-being of America's children. We are committed to following Secretary Thompson's lead on prevention efforts and to working with our sister agencies at the Department of Health and Human Services, especially CDC, to eradicate this health concern. To this end, we are engaged in a number of efforts to address lead poisoning in children, which I will detail for you today.

CMS' ROLE IN PREVENTING LEAD POISONING

The fight to eradicate poisoning from lead-based paint and dust is a collaborative effort, and CMS works closely with other HHS agencies, such as the Centers for Disease Control and Prevention (CDC), as well as the Environmental Protection Agency (EPA), the Department of Housing and Urban Development (HUD), the Department of Justice (DOJ), and other community-based organizations. Medicaid plays a distinct role in addressing lead poisoning by providing funding for four important services: screening, treatment, investigation, and case management for eligible Medicaid beneficiaries.

Medicaid's Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit specifically requires that all Medicaid-eligible children receive a screening blood-lead test at one and two years of age, as recommended by the CDC. Also, any child over age two up to age six for whom no record of a test exists must receive a screening blood-lead test. In addition to paying for the screening tests, Medicaid pays for any additional diagnostic and/or treatment services required for a child with elevated blood-lead levels. This includes any case management services necessary to ensure that the child and family are directed to the appropriate agencies and resources they may need, such as the local health department and housing agencies, medical care and facilities. Once a child is diagnosed as having an elevated blood-lead level, Medicaid also will pay for a one-time investigation. During this investigation, a health professional visits a child's home (or primary residence) and inspects the area to determine the source of lead. We believe that Medicaid has contributed to the dramatic decline in blood-lead levels over the last two decades, however, we are continuing to make improvements in data collection and education with our State partners as well as health care providers.

CMS' COLLABORATIVE EFFORTS AND IMPROVEMENT STRATEGY

As you may know, the General Accounting Office (GAO) released a report in January 1999 that detailed problems in the federal response to children at risk for elevated blood levels. This report provided a roadmap for improvement, and following its publication, CMS entered into a number of activities to improve our services and commitment to helping at-risk children. For example, in 1999 we began efforts to improve the way we collect data on screening tests by adding a line item to the annual EPSDT report that States submit to us. This line item indicates the number of children under the age of six that received a screening blood-lead test. We began collecting this data in April 2000 for FY 1999. However, the reporting of tests and test results always presents a challenge for the Agency. We only gather information on the tests we help to fund. Some tests provided by local health departments through health fairs and other venues are not generally billed to Medicaid. When no Medicaid claim for the test exists, accounting for these tests for the purpose of our annual EPSDT report is made more difficult. We have continued to encourage State Medicaid agencies to participate in data sharing activities so that the local health department and the Medicaid agency are both aware if a test has been performed on a Medicaid-eligible child. Moreover, our Regional Offices work with State and local agencies to help coordinate and support grassroots efforts to educate providers on the importance of blood-lead screening, reporting, and data collection.

Also in 1999 in response to the GAO report, we sent a letter to all State Medicaid directors that detailed the findings of the report and reiterated the responsibilities of each State Medicaid program under the federal Medicaid screening policy. This letter also encouraged States to develop model interagency agreements to share best practices information among the agencies in their State governments. That way, States can better assess the areas and children that lead may affect, and how to prevent and detect lead poisoning.

Building on these efforts, we also have entered into a Cooperative Agreement with the Alliance to End Childhood Lead Poisoning, awarding them $250,000 to develop an educational tool to be used by regional, State, and local Medicaid offices, and other entities who work closely with health care providers and managed care plans involved in screening children. The tool is intended to improve awareness of and compliance with CMS policies on childhood lead poisoning prevention. Our collaborative effort resulted in the development of a guide entitled, Track, Monitor and Respond: Three Keys to Better Lead Screening for Children in Medicaid, which was disseminated to State Medicaid Agencies and is available on the Alliance website. This guide is intended to be an educational document that States can use to reach out to their providers in order to resolve some of the difficulties in the provision of the blood-lead screening tests.

In addition to our work with the Alliance, we awarded a contract for approximately $750,000 to Abt Associates to develop a study titled, Moving Toward Elimination of Lead in High-Risk Children. The purpose of this study is twofold: to improve screening among low-income children by assessing the impact and effectiveness of current screening criteria in reaching high-risk, low-income children (with a particular emphasis on Medicaid-eligible children); and to identify State and local innovations for the elimination of lead hazards facing low-income children. The study is ongoing and will identify and analyze current screening policies and practices for low-income children to determine the extent to which Medicaid and other high-risk children are being screened and whether programs are achieving successful results. The project will include site visits to five locations to provide an in-depth picture of the screening and prevention/remediation activities in five areas - Providence, Rhode Island; Baltimore, Maryland; Chicago, Illinois; the State of Iowa; and Oakland/Alameda County, California. We expect a final report by Fall 2002. We plan to share this report with State Medicaid agencies to assist them in developing the types of processes and practices that will result in more high-risk Medicaid-eligible children receiving the lead screening test to which they are entitled. We believe that the study will show that if local housing and health departments and State Medicaid agencies work together, a child's chances of being screened for lead poisoning and being able to live in lead-safe housing greatly improve.

Just as local and State agencies need to cooperate, federal agencies must work together, too. We collaborate with many other federal agencies on the President's Task Force on Environmental Health Risks and Safety Risks to Children. In February 2000, the Task Force published "Eliminating Childhood Lead Poisoning: A Federal Strategy Targeting Lead Paint Hazards." The report presents a program for eliminating childhood lead poisoning by 2010 based on coordinating the efforts of various federal agencies, including HUD, EPA, CDC and CMS to improve early intervention and follow-up services for at-risk children and to remove lead hazards from homes. We look forward to working with our partner agencies and departments and the States to address the full array of issues surrounding the elimination of childhood lead poisoning.

As we strive to develop a number of strategies to better protect America's at-risk children, we remain committed to our current policy addressing the very real threat posed by lead hazards. Moreover, while we work to ensure that at-risk children, particularly those who are Medicaid-eligible, receive early intervention and treatment for lead poisoning, we will continue to rely on the expertise of the CDC for policy recommendations on lead screening.

CONCLUSION

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