Children at Risk: Gaps in State Lead Screening Policies
The information in this report is the product of extensive research on state and federal websites and numerous phone calls and emails with state and federal staff to clarify ambiguities. The research was primarily conducted in May and June of 2016, with information updated into October 2016 where possible. For many of the states, Safer Chemicals, Healthy Families (SCHF) interviewed staff in both the state lead poisoning prevention program and state Medicaid agency. To determine whether states required proof of a lead test for enrollment in a school or program (other than Head Start), and whether state laws required private insurance to cover the cost of a test, SCHF generally relied on statements by state lead poisoning prevention programs.
This report does not discuss states’ primary prevention programs, such as for lead abatement, or talk about states’ policies for following up on cases of children found to have elevated lead levels. Both of these are critical components of strategies to address lead poisoning.
Reporting Requirements and Data for Tables 1.A – 1.D
For each state, Tables 1.A – 1.D list the type of blood lead testing requirements or recommendations and their test reporting requirements, and estimate their screening rates. In column D of Tables 1.A and 1.B and column B of Tables 1.C and 1.D, “All” means that the state requires all laboratories and at least all health care providers using point-of-care analyzers to report test results to the state.
Three different types of sources can be used for the number of children reported to be tested for lead in a state on an annual basis. Most states provide their own data, and the Centers for Disease Control and Prevention (CDC) maintains two databases housing state data. One is part of the agency’s lead program, which processes raw state data and displays it in the National Surveillance Data spreadsheet accessed via http://www.cdc.gov/nceh/lead/data/national.htm. The agency’s Environmental Public Health Tracking Program (referenced here as “Tracking Program”) also displays childhood lead poisoning data, which CDC takes directly from the states that provide it and posts without running the data through any screens. If states do not provide data, the Tracking Program uses National Surveillance Data. In addition to the level of processing, the two CDC databases differ in the type of data shown. The Tracking Program provides annual numbers and percentages for children given a lead test in the age groupings (a) birth to under 36 months and (b) 36 months to under 72 months. The National Surveillance Data displays the total number of children tested under 72 months only.
The critical ages to identify children with lead poisoning are around 1 and 2. The Tracking Program’s data on the percentage of children tested under 36 months provides a better approximation of how many children were tested close to these critical ages than the data on children tested under 72 months. Therefore, SCHF gathered the most recent and complete percentages for 28 states plus the District of Columbia from this database, and displayed it in the columns entitled “% of kids <36 mo. tested” (column E in Tables 1.A and 1.B; column C in Tables 1.C and 1.D). The numbers are from 2014 except where noted. Data on this measure for two states were taken directly from state reports.
We also display the percentages of children tested under 72 months in the tables below (column F in Tables 1.A, 1.B, and column D in Tables 1.C, 1.D). Most states display their data in this grouping. In addition, one state (Iowa) requires children to have one lead test by age 6 (or as soon as possible after) on enrollment to kindergarten.
Data for 33 states plus DC on the number of children tested under 72 months were taken from the most recent and complete numbers in the National Surveillance Data spreadsheet; that data is from 2015 except where noted. We divided the number of children under 72 months old that were reported screened by the total population under 72 months listed there.
We did not find reliable data on this measure (<72 mo.) for seven states in either of the CDC databases, so our analysis for those relied on recent state reports. The total population of children younger than 72 months was not available from two of the state reports, so we used 2010 Census data. Nine states did not have complete data that was more recent than 2010 on CDC’s databases or in state reports; seven of these do not require all results to be reported.
No state requires tests for children every year from birth to age 3 or to age 6, so a 100% testing rate is not expected. The percentages of children tested at younger than 36 months are higher than those for all children under 72 months because most of the lead tests from birth to 6 years of age happen around ages 1 and 2.
The states are ordered by the percentage of children tested under 36 months where available, then by the percentage of children tested under 72 months, and then alphabetically.
The data in column G of Table 1.A, “% of kids tested in target age range,” are from state reports or correspondence with state staff. These percentages compare the number of tests reported in universal testing states to the states’ testing requirements, and in some cases look at the percentage of children tested by only one of the required ages.
The policies described in Tables 1.A – 1.D are current state policies that were generally in effect during the years for which the screening data was reported. Two notable exceptions are Maryland and Washington State, which adopted new testing programs after their data was reported.
In this report, because inconsistencies and other concerns with the available data make it impossible to develop a true ranking, we intentionally avoid ranking one state’s program against another, and instead only seek to compare the different aspects of the programs and the available results.
Data for Table 2
The percentages in bold are official benchmarks from the Healthcare Effectiveness Data and Information Set (HEDIS®) Medicaid measure of “Lead Screening in Children,” from the National Committee for Quality Assurance’s (NCQA) Quality Compass® 2015 edition. These represent the number of children in 2014 who received at least one blood lead test by age 2, divided by the number of children enrolled in Medicaid for at least 12 months before their second birthday. The benchmarks are from the states with at least five Medicaid plans reporting on this measure. Note that the numbers may not reflect all Medicaid plans in a given state since all may not report to NCQA. For states without NCQA benchmarks (non-bold text), SCHF averaged individual plan rates provided by NCQA.
The benchmarks and rates derived from NCQA data do not show how many children received two tests by age 2 as required by the Centers for Medicare and Medicaid Services. In addition, because all Medicaid plans in a particular state may not report, these data may not accurately reflect the actual percentage of children with at least one test by age 2.
Read the Full Report
- III.Federal Testing Policies and Funding
- IV.State Lead Screening Policies and Reporting Requirements
- V.State Policies for Testing Medicaid-enrolled Children
- VI.Best Practices: Highlights From Successful Programs
- VII.Universal versus Targeted Screening
- VIII.Conclusion and Recommendations
- X.Table 1.A
- XI.Table 1.B
- XII.Table 1.C
- XIII.Table 1.D
- XIV.Table 2