Letter to Mr. Andrew M. Slavitt, Acting Administrator of the Centers for Medicare & Medicaid Services - Update Lead Screening Policy to Protect Children

Letter

Dear Acting Administrator Slavitt:

We write to urge the Centers for Medicare & Medicaid Services (CMS) to reevaluate its policy regarding lead screening for Medicaid-eligible children, and to identify and disseminate best practices for states to reduce barriers to blood lead screening and testing for children across the country. We also urge you to work within the agency and alongside federal and state partners to identify and support opportunities to enhance lead screening adherence, treatment regimens, and lead abatement activities.

According to a recently published Reuters investigation Unsafe at Any Level, our country is failing when it comes to screening and testing at-risk children for lead. Data from the Centers for Disease Control and Prevention (CDC) shows that children in at least four million households across the United States are exposed to high levels of lead -- whether from paint, contaminated soil, water, toys, or other household items. More than half a million children, aged one to five, are estimated to have blood levels above the level at which the CDC recommends public health actions be taken (5 mcg/dL). However, millions of at-risk children are never screened and tested for high lead levels, despite early childhood lead screening and testing requirements. The devastating impact of lead poisoning requires that CMS do everything it can to help healthcare providers quickly identify and track children who have been exposed to lead.

First, CMS should review and update its Medicaid and Children's Health Insurance Program (CHIP) lead screening protocols. Since 1989, federal law has required lead screening "as appropriate for age and risk factors" for all children enrolled in Medicaid. Blood lead screenings are covered under Medicaid's Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. CMS policy between 1989 and 2010 required that all children insured by Medicaid receive a blood lead screening at 12 months and 24 months of age. Despite these universal screening requirements, a Government Accountability Office (GAO) report published in 1999 found that less than 20 percent of Medicaid-eligible children were being screened for lead. More than 15 years later, our lead screening rates are still dismal. According to the recent Reuters investigation that examined data from almost a dozen states, less than half of the one- and two-year-olds enrolled in Medicaid -- just 41 percent -- are tested for lead exposure as required.

In 2012, CMS updated its policy to align with recommendations from the CDC and to provide states with flexibility so they could focus on improving lead screening rates for Medicaid-eligible children most at risk for lead exposure. As a result of this policy change, current policy allows states to obtain approval from CMS to use a targeted high-risk lead screening approach, instead of screening all Medicaid-eligible children at ages 12 and 24 months. Despite this attempt to provide additional flexibility to states, millions of at-risk children still fail to receive appropriate blood level screening. While only one state thus far has been granted a waiver to move from universal to targeted screening, we feel strongly that CMS, in collaboration with the CDC, should reevaluate and update its policies so that all at-risk children are appropriately screened for lead poisoning.

Second, CMS should develop strategies to enhance adherence to lead screening policies by providing states with guidance on opportunities to maximize screening and testing in their states. There are many barriers beyond current CMS policy that prevent children from getting screened and tested: providers frequently do not know whom they are required to screen and test, parents often lack the information they need to determine whether or not their child is "at-risk" and should be tested, reimbursement rates remain low for providers in many states, and there are few policies in place to ensure adherence to current CMS policies on lead screening.

In order to ensure all at-risk children are appropriately screened, CMS should work to identify potential barriers to screening and testing and provide resources for states to overcome these challenges. CMS should facilitate partnerships between state Medicaid offices and other state and federal partners to ensure states are utilizing every resource available to fulfill their responsibility to screen children and eradicate lead exposure. For example, CMS could issue joint-guidance to state Medicaid offices and Women, Infants, and Children (WIC) agencies or Head Start programs on ways state agencies can coordinate and partner to identify and screen at-risk children. By improving coordination between programs and providing opportunities for screening and testing in non-traditional settings, states can maximize their referral networks and streamline lead screening opportunities.

In addition, CMS should evaluate and promulgate guidance on alternative methods for screening and testing that may help states meet their screening requirements. For example, screening and testing at the point-of-care -- as opposed to sending out samples to a laboratory -- may provide an opportunity to increase compliance with screening mandates, as well as improve care and efficiency for at-risk children and their families. Pilot studies show that it is possible to use the same blood draw to perform point-of-care blood lead testing and other screenings. By providing alternative ways for children to be screened and tested, communities with lead challenges may be able to improve compliance and identify at-risk children early on.

Third, we urge CMS to partner with federal and state partners to identify lead abatement opportunities and support follow-up treatment for children who have elevated blood lead levels. As you know, when dealing with lead poisoning, early intervention is crucial. Children who are not regularly screened often go undiagnosed and untreated for elevated lead levels because of the lack of identifiable symptoms. Unfortunately, we have seen what happens when lead exposure is overlooked: serious damage to the heart, kidneys, reproductive system, brain and central nervous system. Lead exposure is particularly harmful to the developing brains and nervous systems of young children--even low levels of exposure are associated with irreversible neurologic damage and behavioral disorders. We cannot afford to let more children suffer the consequences of a lack of attention to this issue.

CMS policy on follow-up care for children with elevated blood lead levels requires that state Medicaid programs cover environmental investigation and case management services. Yet, state Medicaid programs vary in their compliance with these follow-up and treatment services. We urge CMS to develop a strategy to enhance adherence to lead screening policies and ensure adequate follow-up care for children with elevated blood levels.

The tragedy in Flint, Michigan, and the presence of lead in water supplies and housing and schools across the country require that we review and re-examine how we can best screen for, treat, and prevent lead poisoning. We must work to ensure that we are reaching, as early as possible, children at risk of elevated blood lead levels. Accordingly, we ask that CMS reexamine and update its policy regarding lead screening for Medicaid-eligible children, provide guidance on how states can increase adherence to blood lead screening and testing for children, and work with partners to identify lead abatement opportunities and support treatment regimens.

We look forward to your prompt attention to this issue, and your response.