Mitigating Childhood Lead Exposure and Disparities: Medicaid and Other Federal Initiatives
Lead exposure has well-documented long-term health and developmental impacts for children. As evidenced by the Flint Michigan water crisis, one way people may be exposed to lead is through water service lines, but exposure may also occur through other sources of lead in homes and neighborhoods. Although the Centers for Disease Control and Prevention (CDC) Healthy People 2020 goals to reduce blood levels in children were exceeded, disparities persist, with lower-income households and children of color continuing to be at increased risk for lead exposure. Consistent with other preventative health screening trends, data suggest that lead screening may have declined amid the COVID-19 pandemic and exacerbated underlying disparities in early identification and intervention. As a major source of health coverage for low-income children and children of color, Medicaid can help to mitigate lead exposure and its impacts. Medicaid requires lead screening and testing for children that can facilitate early identification and intervention for lead exposure. In addition, there are a range of federal and state initiatives underway to address lead exposure and its health impacts.
To provide further insight into these issues, this brief examines:
- How are people exposed to lead and what are the health impacts of lead exposure?
- Who is at increased risk for lead exposure?
- What are lead screening guidelines and how has lead screening been affected by COVID-19?
- How can Medicaid mitigate lead exposure and its health impacts?
- What are other current federal initiatives that seek to reduce lead exposure?
How are people exposed to lead and what are the health impacts of lead exposure?
In the U.S., individuals may be exposed to lead through multiple sources in their home or environment. Homes built before 1978 — when the federal government banned consumer uses of lead-based paint — likely contain lead-based paint, which may create lead dust when it peels or cracks. Older homes also may have pipes, faucets, and plumbing fixtures containing lead. Moreover, at least 6 million lead service lines exist in water delivery infrastructure, schools, and businesses. Lead can also be found in some products, such as toys and jewelry and in some imported food or medicine. Other sources of lead exposure may include certain jobs, such as manufacturing or construction, and/or contaminated soil.
Exposure to lead can seriously harm a child’s health, including damage to the brain and nervous system, slowed growth and development, learning and behavior problems, and hearing and speech problems. The effects of lead on the nervous system can cause lower IQ, decreased ability to pay attention, and under performance in school. The CDC indicates that these health effects are more harmful to children under age six, whose bodies are still developing and growing rapidly. In addition, younger children are at increased risk for exposure, since they are more likely to put their hands or other objects in their mouth, which may be contaminated with lead. In addition, lead exposure during pregnancy can increase risk for miscarriage, premature birth, and other developmental effects for babies. Blood lead levels rise after ingestion of lead and gradually decrease when exposure stops. Persistent blood lead level elevations may require therapy to remove heavy metals from the body to avoid irreversible damage to multiple body systems.
Who is at increased risk for lead exposure?
Disparities in lead exposure persist for lower-income households and neighborhoods and children of color. Data show that although Healthy People 2020 objectives to reduce overall blood levels in children have been exceeded, Black children and those living in households with incomes below 130% of the federal poverty level (FPL) remain at increased risk for exposure (Figure 1). Data were not reported for other broad racial/ethnic groups. Other research has found higher proportions of detectable and elevated blood lead levels among children with public insurance, who are more likely to be low income and found the share of children with elevated blood levels increased as degree of poverty increased. Similarly, research show that areas with higher blood lead levels are associated with low home ownership, high poverty, and residents who are a majority people of color. Some research also suggests some groups of Hispanic and Asian children are at increased risk for lead exposure. Similar patterns are observed among pregnant women, with studies finding higher levels of lead among Black and Hispanic women compared to White women, as well as higher levels among women residing in areas with higher crime, greater diversity, lower educational attainment, lower household income, and higher poverty. Lead poisoning also disproportionately affects refugee and other immigrant children due to both environmental exposures, such as resettling in pre-1978 housing, and potential exposure through cultural practices, traditional medicines, and consumer products. For example, refugees and other newcomer populations may use or consume imported products contaminated with lead, such as traditional remedies, herbal supplements, spices, candies with lead in the wrappers, cosmetics, or jewelry. Indigenous people may also be at increased risk of being exposed to lead through certain traditional practices, such as lead contamination of plants and animals in traditional diets, and older housing.
What are current lead screening guidelines and how has lead screening been affected by COVID-19?
The Centers for Disease Control and Prevention (CDC) recommends testing blood for lead exposure because there often are no immediate symptoms when a child is exposed to lead. The amount of lead in blood is referred to as the blood lead level, which is measured in micrograms of lead per deciliter of blood. While no level of lead in the blood is identified as safe, the CDC uses a blood lead reference value (BLRV) of 3.5 micrograms per deciliter to identify children with blood lead levels that are higher than most children’s levels. This level is based on the 97.5th percentile of blood lead values among U.S. children ages 1-5 years from the National Health and Nutrition Examination Survey; children with blood lead levels at or above the BLRV represent the top 2.5% blood lead levels. In 2021, the CDC decreased the reference value from 5.0 to 3.5 micrograms per deciliter to facilitate earlier intervention and identification of at-risk children even as overall lead levels among children in the U.S. have been decreasing. If a child has a blood level value above the BLRV, their doctor may recommend services for treatment and/or to remove lead from the environment.
There are no recommendations for universal lead screening among children, but screening is recommended for children and pregnant and breastfeeding women who are at higher risk for exposure. These include Medicaid-eligible children, those living in areas with older housing, and those in areas where higher shares of younger children have elevated blood levels as well as pregnant women in communities with high risk of lead exposure. The CDC also discourages breastfeeding among mothers with elevated blood lead levels. Given local variation in presence of risk factors, the American Academy of Family Physicians recommends following CDC screening guidelines in addition to using targeted screening questionnaires to identify children who may be at increased risk for lead poisoning. States also offer varied guidance for lead screening, management, and reporting
Consistent with other preventive health screening trends, data suggest that lead screening may have declined amid the COVID-19 pandemic and exacerbated underlying gaps and disparities in early identification and intervention. The CDC reports that from January-May 2020, 34% fewer U.S. children had blood lead level testing compared to the same period in 2019, with an estimate of 9,603 children with elevated blood lead levels missed. Between May 2019 and 2020, screenings fell by over 50%, with even larger fall offs in some states. For example, Michigan, Delaware, and Colorado all reported screenings fell by over 70% between May 2019 and 2020. The Healthcare Effectiveness Data and Information Set (HEDIS) measure for lead screening in children in Medicaid MCOs shows a decline from 70.0% in 2019 to 68.3% in 2020.
How can Medicaid mitigate lead exposure and its health impacts?
Medicaid covers lead testing through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit and has specific requirements for lead screening of children. Guidance suggests that states must ensure that all children enrolled in Medicaid receive lead screenings at ages 12 months and 24 months; additionally, any child between 24 and 72 months with no record of a previous blood lead screening should receive one. Separate Children’s Health Insurance Program (CHIP) programs do not have the same requirements for universal lead screening as Medicaid, although the Centers for Medicaid and Medicare Services (CMS) encourages states to align CHIP and Medicaid screening policies. Despite requirements for lead screening, gaps in lead screening persist. Research has found that adherence to the Medicaid screening requirements is variable across states.
Beyond lead screening for children, consistent with Medicaid EPSDT benefit requirements, states are required to provide medically necessary diagnostic and treatment services for children identified with elevated blood lead levels. Additionally, Medicaid may provide case management and a one-time investigation to determine the source of lead for children with elevated blood lead levels. While Medicaid reimburses for lead investigations in the home or primary residence of a child with an elevated blood level, it does not cover lead abatement services.
Medicaid strategies to mitigate lead exposure include collaboration between Medicaid and state’s health departments and lead poisoning and prevention programs to reach children who have not received required blood lead screening tests. Partnering with providers can help with outreach and education efforts to promote screening and then to connect families to resources for lead mitigation within homes. Data sharing agreements between Medicaid and other state agencies can help identify children who may have not received lead screening. In addition, states can improve oversight and monitoring to include more frequent audits and meaningful enforcement or corrective action plans to increase lead testing. For example:
- In Wisconsin an effort to link Medicaid billing data to blood lead data helped identify Medicaid-enrolled children who had not received the required tests. Providers were notified of children within their practice who had not been tested. The share of Medicaid-enrolled children who received an age-appropriate test increased from 46% to 55% over the project period.
- New York had implemented a strategy to coordinate agencies and improved point of care testing for high-risk mothers. More recently, the state has implemented its First 1,000 Days on Medicaid Initiative to improve access to services for young children covered by Medicaid, including lead screening and testing.
CMS guidance outlines a number of strategies with Medicaid managed care organizations (MCO) to improve lead screening for children. For example, states can include lead screening requirements in managed care contracts and require collection and reporting of quality measures like the HEDIS lead screening measure. Federal regulations mandate that states require Medicaid managed care plans to establish and implement an ongoing comprehensive quality assessment and performance improvement program for Medicaid services that includes Performance Improvement Projects (PIPs). PIPs may be designated by CMS, by states, or developed by health plans, but must be designed to achieve significant, sustainable improvement in health outcomes and enrollee satisfaction. States can also require managed care plans to implement PIPs focused on blood lead screenings or include lead screening improvements in the Quality Assessment and Performance Improvement Programs (QAPI). States can also link MCO payment incentives such as bonuses or penalties, quality add-on payments, or managed care capitation withholds to performance measures that promote increases in lead screening. For example:
- In California, managed care plans are contractually required to cover and provide lead screening tests in accordance with state regulations and must ensure network providers report blood lead screening test results to the Department of Health’s Childhood Lead Poisoning Prevention Branch.
- Multiple states (including Connecticut, Georgia, Florida, Illinois, Iowa, Maine, Maryland, New Jersey, and Tennesseehave adopted PIP and/or value-based bonus payments for Medicaid managed care plans aimed at improving rates of lead screening and follow-up, as well as case management for home and environmental lead investigation (and subsequent connection to abatement resources).
Health Services Initiatives (HSI’s) authorized under CHIP allow for broader lead abatement activities than allowed under Medicaid. While Medicaid cannot be used to abate or remediate environmental risks, CHIP Health Services Initiatives (HSIs) can be used for this purpose. Under CHIP, states can implement HSIs to improve the health of low-income children and can include both direct services and public health initiatives such as lead education and case management. CMS guidance has provided examples of state-designed HSIs to increase blood lead screening rates for young children. A https://www.nashp.org/leveraging-chip-to-improve-childrens-health-an-overview-of-state-health-services-initiatives/ (including Indiana, Maryland, Michigan, Missouri, Ohio, and Wisconsin) have HSIs focused on improving lead testing, prevention and paying for abatement, which includes efforts to remove lead-based paint, replacing tainted household components, and removal of lead hazards, many of which define an approach prioritizing high-risk neighborhoods.
Medicaid Section 1115 waivers may offer additional opportunities to address long-term health impacts of lead exposure and focus on impacted communities. For example, Michigan used a Medicaid section 1115 waiver to support its response to the Flint Water crisis (Box 1).
The Flint water crisis was a public health crisis that began in 2014, when the city switched its drinking water supply from Detroit’s system to the Flint River without adequate water treatment and testing for corrosion to prevent lead release from plumbing, which ultimately resulted in increased contamination and lead exposure for Flint residents. The crisis had greater impacts on people of color and under resourced areas, as Flint residents are predominantly lower income and disproportionately Black. Moreover, some Spanish-speaking residents in Flint did not learn about the water crisis until months after it began. Research showed increased incidence of elevated blood lead levels.
In response, Michigan sought and received expedited approval for a Section 1115 Medicaid waiver as well as a CHIP HSI to expand Medicaid eligibility for an estimated 15,000 children and pregnant women up to 400% of the Federal Poverty Line (FPL) in the Flint area, waive CHIP premiums for all children served by the Flint water system, and offer face-to-face targeted care management services to all impacted Medicaid-eligible children and pregnant women. Waiver evaluation data suggest high rates of lead screening among children and pregnant women covered under the waiver. In September 2021, CMS approved an extension of Michigan’s waiver, which demonstrated improvement in lead screening for children and eligible pregnant women.
A range of other efforts and funding helped provide lead abatement, create a registry to help monitor health outcomes, and coordinate services for lead-exposed individuals. Data from the Flint’s 2021 Lead Free report found that improvements residential water sources with high lead levels.
What are other current federal initiatives that seek to reduce lead exposure?
Beyond initiatives within Medicaid, the Biden administration and Congress have taken a range of actions focused on mitigating lead exposure and disparities.
- The March 2021 COVID-19 relief legislation, the American Rescue Plan Act (ARPA), provided investments in infrastructure, including replacement of lead service lines and lead hazard remediation, as well as targeted efforts to remove lead lines from federally assisted housing, schools, and child care centers. The U.S. Department of Education will use the American Rescue Plan Elementary and Secondary School Emergency Relief and State and Local Relief funds to reduce lead exposure and address lead-contaminated drinking water in schools.
- In October 2021, the U.S. Environmental Protection Agency (EPA) released its draft Strategy to Reduce Lead Exposure and Disparities in U.S. Communities for Fiscal Years 2022-2026, expanding upon goals laid in the 2018 Federal Action Plan to Reduce Childhood Lead Exposure and supporting the January 2021 Executive Order on Advancing Equity and Support for Underserved Communities through the Federal Government. The draft Lead Strategy identifies four goals including: (1) reducing community exposures to lead sources, (2) identifying lead-exposed communities and improving their health outcomes, (3) communicating more effectively with stakeholders, and (4) supporting and conducting critical research to inform efforts to reduce lead exposures and related health risks.
- In November 2021, Congress passed the Infrastructure Investment and Jobs Act which dedicates $55 billion to expanding access to clean drinking water, eliminating lead service lines, and addressing industrial pollution sites. The bill will additionally invest $21 million to clean up Superfund and brownfield sites, which can lead to elevated blood lead levels among children in their proximity.
- In December 2021, the Administration released the Lead Pipe and Paint Action Plan, which accelerates the earlier infrastructure investments and includes over 15 new actions from over ten federal agencies with aims to replace all lead pipes in the next decade. These actions include collaboration with local, state, and federal partners to accelerate lead pipe replacement over the next decade, prioritization of underserved communities, and launching of a new EPA regulatory process to protect communities from lead in drinking water. As part of the Lead Pipe and Paint Action Plan, a cabinet level partnership the EPA, Department of Education, Department of Health and Human Services, and Department of Agriculture will focus on lead remediation across schools and daycare centers. Under the Action Plan, HHS will support ongoing lead poisoning prevention through the Childhood Lead Poisoning Prevention Program (CLPPP), which has funded over 60 state and local childhood lead poisoning prevention program and maintains the Childhood Blood Level Surveillance System and Healthy Homes Lead Poisoning Surveillance Software platform.
- In February 2022, the EPA announced $20 million in grant funding to assist communities and schools with removing lead sources in drinking water, with prioritization of small, underserved, and disadvantaged communities. Through the Water Infrastructure Improvements for the Nation (WIIN) Act, the EPA announced the availability of $10 million for projects to conduct lead service line replacements or corrosion control and $10 million for efforts to remove lead in drinking water in schools or childcare.
Building on prior work, the EPA is providing additional support for addressing lead exposure among Tribal communities. In 2020, the EPA announced a new grant program of $4.3 million for Tribes to reduce lead in drinking water in schools. Since then, the EPA has worked with over 200 Tribal partners to design a curriculum to raise awareness in Tribal communities about childhood lead exposure, expand understanding of lead’s impact on children’s health and cultural practices and diets, and encourage actionable prevention of lead exposure. While limited data is available to assess the success of the curriculum, prior work has found that community-based health advisors and youth engagement focused on improving lead poisoning prevention (including washing hands before meals and snacks) lead to significant improvements for American Indian children. As part of the Lead Pipe and Paint Action Plan, the EPA will update the Safe Drinking Water Information System to support state and Tribal data management needs for inventories and allocate $2.9 billion in Bipartisan Infrastructure Law funding to states, Tribes, and territories to remove lead service lines.
Key Tenets of the Biden-Harris Lead Pipe and Paint Action Plan
Get Resources to Communities. The EPA announced that it will allocate $2.9 billion in Bipartisan Infrastructure and encourage states to use funds to advance proactive lead line replacement programs, prioritizing disadvantaged communities and partnering with states to provide technical assistance to help marginalized communities overcome barriers to funding through State Revolving Fund (SRFs) programs. The 2022 allocation is the first of five years of $15 billion in dedicated EPA funding for lead serve lines states will receive from the Bipartisan Infrastructure Law. The EPA Office of Water will issue national program guidance to states on water infrastructure funding and will include directions on the $15 billion in dedicated lead service line funding. The EPA will additionally establish Technical Assistance Hubs in select regions with large concentrations of lead service lines. Furthermore, the Department of Housing and Urban Development (HUD) awarded $13.2 million to state and local government agencies through the Lead Based Paint Hazard Reduction (LBPHR) program, targeting specific high-risk communities initially.
Updates Rules and Strengthen Enforcement. On December 16, 2021, the EPA announced next steps to strengthen the regulatory framework on drinking water lead. The EPA announced additions to the National Primary Drinking Water Regulation: Lead and Copper Rule Revisions (in effect December 2021), outlining steps local water systems should take to achieve complete lead service replacement in addition to oversight and technical assistance for communities impacted by high lead blood levels.
Reduce Exposure in Disadvantaged Communities, Schools, Daycare Centers, and Public Housing. The CDC announced through the Childhood Lead Poisoning Prevention Program (CLPPP) (authorized under the Lead Contamination Control Act of 1988) an intent to eliminate childhood lead poisoning as a public health problem by strengthening blood level testing, reporting, and surveillance (providing education and outreach to communities), and linking exposed children to services. Additionally, the goals of the new cabinet level partnership developed under the Action Plan include identifying priority areas for inter-agency coordination, funding alignment opportunities, addressing data gaps, and developing of coordinated guidance to reduce lead exposure in schools and childcare facilities. The HUD and the Department of Interior (DOI) will work to eliminate hazards in federally-assisted housing, including tribal housing by replacing lead services lines whenever water main feeder laces are replaced and mitigating or eliminating lead paint hazards when rehabilitating housing. The USDA will pursue actions through its Rural Development Mission Area Community Facilities Programs, which funds eligible projects for water filter station installation in schools and childcare facilities to prevent lead poisoning.