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Endnotes

Endnotes

  1. In correspondence with SCHF, staff in two states indicated their reporting requirement for in-office testing only applied to users of specific point-of-care machines (LeadCare® II).
  2. CDC’s National Surveillance Data can differ from states’ data because CDC runs states’ raw data through various screens that may vary from how the states prepare their data for the public. In addition, four states indicated that they updated their data after providing it to CDC and CDC may not have received the updates. Note CDC’s disclaimer on its website -“These data were collected for program management purposes. The data have limitations, and we cannot compare across states or counties because data collection methods vary across grantees. Data are not generalizable at the national, state, or local level. The chart represents only state-specific data and is not a population-based estimate, so we are not able to compare states against one another.”
  3. CDC, “National Environmental Public Health Tracking Network,” last updated September 25, 2015, http://ephtracking.cdc.gov/showHome.action; CDC Environmental Public Health Tracking Program staff, Personal communication, October 28, 2016
  4. The states are Illinois and Louisiana. The percentage for Illinois was calculated based on numbers in the state report. For Louisiana, we used 2010 census data as the denominator to calculate the screening rate since the state did not provide the relevant population numbers.
  5. The states are: Alaska, Illinois, Iowa, Louisiana, Nebraska, Texas, and Wyoming.
  6. Nebraska and Wyoming did not provide population data. U.S. Census Bureau, “American FactFinder” (data found under “Age,” “2010 Census,” “Single Years of Age and Sex”), generated by Jennifer Dickman using American FactFinder, October 17, 2016, http://factfinder2.census.gov. We used this data by adding together the population numbers for children under 5 with those aged 5 to obtain the population under age 6.
  7. Quality Compass 2015 is the source for benchmark data, shown in bold in Table 2, and the individual plan data used to calculate the rates for the other states, shown in non-bold text. This data is used with the permission of the National Committee for Quality Assurance (NCQA). Quality Compass 2015 includes certain HEDIS data. Any data display, analysis, interpretation, or conclusion based on these data is solely that of the authors, and NCQA specifically disclaims responsibility for any such display, analysis, interpretation, or conclusion. Quality Compass® and HEDIS® are registered trademarks of NCQA.
  8. A similar measure is found on CMS Form-416, where CMS requires states to submit annual data on the number of screening blood lead tests for children under 6. Since a child can have more than one screening blood lead test in a given year, this data does not necessarily show the number of unique children who are tested. “CMS-416 Final Revised Instructions Questions and Answers February 2015,” Medicaid.gov, answer to Question 13, https://www.medicaid.gov/medicaid/benefits/downloads/416-faqs.pdf
  9. Note that lead was not entirely removed from these items – paint for consumer uses can still contain 0.009% lead by weight; the limit has been in effect since 2009. 16 C.F.R. 1303.1. Pipes, pipe and plumbing fittings, and fixtures are allowed to contain 0.25% lead across the wetted surface; solder and flux are allowed to have 0.2% lead, effective since 2014. Environmental Protection Agency (EPA), “Section 1417 of the Safe Drinking Water Act: Prohibition on Use of Lead Pipes, Solder, and Flux,” last updated November 23, 2015, https://www.epa.gov/dwstandardsregulations/section-1417-safe-drinking-water-act-prohibition-use-lead-pipes-solder-and. Lead was first limited in paint for consumer uses to 0.06% by weight in 1978. Pipes, solder, and flux could contain any amount of lead until 1986, when the maximum allowable lead content was set at 8% and 0.2% for pipes and solder/flux, respectively. Chicago even required lead pipes to be used until the mid-1980s. Hawthorne, Michael and Jennifer S. Richards, “Chicago often tests water for lead in homes where risk is low,” Chicago Tribune, February 26, 2016, http://www.chicagotribune.com/news/watchdog/ct-chicago-lead-pipes-water-testing-met-20160226-story.html. The sale of leaded gasoline for on-road vehicles was phased out by 1996; other uses are still allowed today. EPA, “EPA Takes Final Step in Phaseout of Leaded Gasoline,” January 29, 1996, https://archive.epa.gov/epa/aboutepa/epa-takes-final-step-phaseout-leaded-gasoline.html
  10. Study: U.S. Department of Housing and Urban Development, “American Healthy Homes Survey: Lead and Arsenic Findings,” April 2011, pp. 4, ES-1, and ES-8, http://portal.hud.gov/hudportal/documents/huddoc?id=AHHS_Report.pdf. A 2016 New York Times article indicates this is the most recent data. Wines, Michael, “Flint Is in the News, but Lead Poisoning Is Even Worse in Cleveland,” The New York Times, March 3, 2016, http://www.nytimes.com/2016/03/04/us/lead-paint-contamination-persists-in-many-cities-as-cleanup-falters.html.
  11. See pub. 1 in fn10, at p. 4 and ES-2; 34, 23 and 3.6 million represent 32%, 22%, and 3% of the total housing stock, estimated at 106 million. Id., at ES-1
  12. Lanphear BP, et al., “Environmental lead exposure during early childhood” [published correction appears in J Pediatr. 2002;140(4):490], J Pediatr. 2002;140(1):43-44, http://www.ncbi.nlm.nih.gov/pubmed/11815762
  13. Agency for Toxic Substances & Disease Registry, “Public Health Statement for Lead,” August 2007, http://www.atsdr.cdc.gov/phs/phs.asp?id=92&tid=22
  14. CDC, “Lead: What Do Parents Need to Know to Protect Their Children?” last updated March 15, 2016, https://www.cdc.gov/nceh/lead/acclpp/blood_lead_levels.htm
  15. AAP Council on Environmental Health, “Prevention of Childhood Lead Toxicity,” Pediatrics, 2016;138(1):e20161493, p. 3, http://pediatrics.aappublications.org/content/early/2016/06/16/peds.2016-1493
  16. See fn13
  17. Advisory Committee on Childhood Lead Poisoning Prevention, “Interpreting and Managing Blood Lead Levels MMWR Recommendations and Reports, 56(RR08);1-14;16, November 2, 2007, http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5608a1.htm
  18. A few publications assert that the effects of even low BLLs (related to IQ, behavioral issues, etc.) “appear to be irreversible” (e.g. – Advisory Committee on Childhood Lead Poisoning Prevention, “Low Level Lead Exposure Harms Children: A Renewed Call for Primary Prevention” January 4, 2012, https://www.cdc.gov/nceh/lead/acclpp/final_document_030712.pdf), but scientists are looking into what may be promising interventions in the areas of nutrition and intellectual/environmental stimulation to mitigate the negative impacts to an extent. Shell, Ellen Ruppel, “The Brains of Flint’s Children, Imperiled by Lead, Could Still Escape Damage,” Scientific American, July 1, 2016, http://www.scientificamerican.com/article/the-brains-of-flint-s-children-imperiled-by-lead-could-still-escape-damage/
  19. See fn17
  20. See fn15, at p. 5
  21. Wengrovitz, Anne and Mary Jean Brown, “Recommendations for Blood Lead Screening of Medicaid-Eligible Children Aged 1–5 Years,” MMWR Recommendations and Reports, August 7, 2009, 58(RR09);1-11, http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5809a1.htm
  22. Id.; For the specific ages, see fn17, discussing CDC’s recommendation on how states should implement their targeted testing strategies. In 2009, CDC’s Advisory Committee wrote that in 1997, CDC recommended testing children only at age 3 if not previously tested, instead of from ages 3-6 or 36-72 months, in the situation where a state did not have enough data to develop a targeted testing plan. See fn21. This may be an outlier, as other publications reviewed by SCHF consistently discussed testing up to 72 months if there was no previous test.
  23. CDC Advisory Committee on Childhood Lead Poisoning Prevention, “Low Level Lead Exposure Harms Children” January 4, 2012, p. 23, https://www.cdc.gov/nceh/lead/acclpp/final_document_030712.pdf. In addition to the general recommendations for non-Medicaid-enrolled children, CDC provides specific recommendations for testing children who are refugees or international adoptees. CDC also recommends blood lead testing for pregnant women. CDC, “At-Risk Populations,” last updated February 23, 2015, https://www.cdc.gov/nceh/lead/tips/populations.htm
  24. See fn14; CDC, “CDC Response to Advisory Committee on Childhood Lead Poisoning Prevention Recommendations in ‘Low Level Lead Exposure Harms Children: A Renewed Call of Primary Prevention,’” June 7, 2012, http://www.cdc.gov/nceh/lead/acclpp/cdc_response_lead_exposure_recs.pdf. This level will be updated every four years if warranted by new data. (See fn14.)
  25. The U.S. Department of Housing and Urban Development (HUD) recently proposed to initiate an environmental investigation and remediation of lead hazards in paint or soil of HUD-assisted housing when an occupant under age 6 is found to have a BLL of at least 5 μg/dL; the current trigger for intervention is 20 μg/dL. O’Brien, Matt, “HUD proposes lowering acceptable lead level for children,” Business Insider, August 31, 2016, http://www.businessinsider.com/ap-hudproposes-lowering-acceptable-lead-level-for-children-2016-8. Many states have adopted 5 μg/dL as a level that should, at least, be confirmed through further testing and trigger monitoring once confirmed. According to a 2014 report, CDC believes that a finding of BLLs ≥ 5 μg/dL should trigger follow-up testing and education. Raymond, Jaime, et al., “Lead Screening and Prevalence of Blood Lead Levels in Children Aged 1-2 Years,” Morbidity and Mortality Weekly Report, 63(02);36-42, September 12, 2014, http://www.cdc.gov/mmwr/preview/mmwrhtml/su6302a6.htm
  26. See fn14; CDC, “Preventing Lead Poisoning in Young Children: Chapter 1,” 1991, Summary, http://www.cdc.gov/nceh/lead/publications/books/plpyc/Chapter1.htm#Summary.
  27. A few documents cited the source for this as the State Medicaid Manual – chapter 5, section 5123.2 D.1, available at https://www.cms.gov/Regulations-and-Guidance/guidance/Manuals/Paper-Based-Manuals-Items/CMS021927.html. This version is from 1998 so it does not reflect the option for targeted screening. The Medicaid law (42 U.S.C. 1396d(r)(1)(B)(iv), defining EPSDT services, as confirmed by a 1999 Medicaid bulletin (https://www.medicaid.gov/Federal-Policy-Guidance/DOWNLOADS/SMD102299.PDF) only requires “lead blood level assessment appropriate for age and risk factors” (emphasis added). Also, this section of the State Medicaid Manual indicates that the requirement is for all children eligible for Medicaid, and CMS policy documents state this as well, but CMS staff stated by phone on June 17, 2016 that practically, the requirement is only for children enrolled in Medicaid. Accordingly, in this report, “enrolled” is generally used to describe the requirement states must comply with.
  28. Mann, Cindy, “Targeted Lead Screening Plans,” Letter, CMCS Informational Bulletin on Medicaid.gov, June 22, 2012, https://www.medicaid.gov/federal-policy-guidance/downloads/cib-06-22-12.pdf
  29. See fn21
  30. See fn28
  31. Ibid.
  32. Centers for Medicare and Medicaid Services staff, Telephone interview, June 17, 2016; Neill, Kevin, “AHCCCS Medical Policy Manual (AMPM) Update, 2015-07,” to Holders of AHCCCS Medical Policy Manuals, April 27, 2015, https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/revisions/2015/WhatsNew07.pdf
  33. Washington State Department of Health, “Blood Lead Testing and Reporting,” accessed on October 21, 2016, http://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/ProfessionalResources/BloodLeadTestingandReporting; Nevada Department of Health and Human Services staff, Telephone interview, July 19, 2016
  34. Committee on Energy & Commerce Democrats, “Pallone & Wyden Ask CMS for Information on Lead Screening Practices,” June 24, 2016, https://democrats-energycommerce.house.gov/newsroom/press-releases/pallone-wyden-ask-cms-for-information-on-lead-screening-practices
  35. CDC, “Preventing Lead Poisoning in Young Children,” August 2005, p. ix, http://www.cdc.gov/nceh/lead/publications/prevleadpoisoning.pdf
  36. Committee on Energy & Commerce Democrats, “In Light of Flint Water Crisis, Committee Democrats Request Information on Federal Investments to Prevent Lead Poisoning,” February 17, 2016, https://democrats-energycommerce.house.gov/newsroom/press-releases/in-light-of-flint-water-crisis-committee-democrats-request-information-on; CDC Healthy Homes and Lead Poisoning Prevention Program staff, Telephone interview, July 27, 2016
  37. CDC, “Fiscal Year 2015 Justification of Estimates for Appropriations Committees,” p. 240, http://www.cdc.gov/budget/documents/fy2015/fy-2015-cdc-congressional-justification.pdf; CDC, “PPHF 2014,” last updated December 9, 2014, http://www.cdc.gov/nceh/lead/funding.htm
  38. See pub. 2 in fn37; CDC, “Fiscal Year 2017 Justification of Estimates for Appropriations Committees,” p. 322, http://www.cdc.gov/budget/documents/fy2017/fy-2017-cdc-congressional-justification.pdf
  39. Note that only the strongest policy is listed for each state – e.g., if a universal testing state also recommended testing under certain conditions, only the universal testing was noted.
  40. Head Start programs are excluded from this category because those testing requirements are linked to state Medicaid/EPSDT policies and are much more common among states. “Proof of lead test” requirements for enrollment in other programs appear to be less common and can help distinguish states.
  41. See fn1
  42. Southern Nevada Health District, “Reportable Diseases and Conditions,” accessed October 21, 2016, https://www.southernnevadahealthdistrict.org/disease-reporting/disease-reporting.php. NRS442.700, 3. states: “Each qualified laboratory that conducts a blood test for the presence of lead in a child who is under 18 years of age shall . . . submit a report of the results of the test to the appropriate health authority in accordance with regulations adopted by the State Board of Health” (emphasis added). However, staff with the Nevada’s Department of Health and Human Services, Division of Public and Behavioral Health stated by email on August 31, 2016 that they were not aware of any such regulations, indicating that this is an empty requirement.
  43. DC: D.C. Mun. Regs. tit. 22, § B7301.1, http://www.dcregs.dc.gov/Gateway/RuleHome.aspx?RuleNumber=22-B7301CT: Conn. Gen. Stat. Sec. 19a-111g, https://www.cga.ct.gov/current/pub/chap_368a.htm#sec_19a-111g; Connecticut Department of Public Health, “Requirements and Guidance for Childhood Lead Screening by Health Care Professionals in Connecticut,” Revised April 2013, http://www.ct.gov/dph/lib/dph/environmental_health/lead/pdf/screening_requirements-2016.pdf;

    DE: 16 Del. C. § 2602(a), http://delcode.delaware.gov/title16/c026/index.shtml

    IA: Iowa Admin. Code r. 641-67.5, .6, http://idph.iowa.gov/Portals/1/Files/LPP/Chapter.641.67.pdf; Note that Iowa does allow for an exemption from this requirement if the Department of Public Health determines on an individual basis that a child is at very low risk for elevated blood lead levels. Id. at 67.4

    LA: La. Admin. Code tit. 48, § 7005, http://www.doa.la.gov/Pages/osr/LAC-48.aspx (Book 2). This state moved to universal screening in 2008 because screening rates weren’t high enough in any parish to provide enough data to figure out which ones were high risk. Lagarde, Gina, “UNIVERSAL Blood Lead Screening of Children under 6 years of Age,” Louisiana Childhood Lead Poisoning Prevention Program, October 23, 2008, https://www.lmmis.com/provweb1/children_lead.pdf. Note that the rates are still not very high.

    MD: Md. Code Regs. 10.11.04.02B(2), .04.A http://www.dsd.state.md.us/comar/SubtitleSearch.aspx?search=10.11.04.*; Maryland Department of Health and Mental Hygiene, “Maryland Targeting Plan for Areas at Risk for Childhood Lead Poisoning,” October 2015, http://phpa.dhmh.maryland.gov/IDEHASharedDocuments/MD%202015%20Lead%20Targeting%20Plan.pdf

    MA: 105 Mass. Code Regs. 460.050, http://www.mass.gov/courts/docs/lawlib/104-105cmr/105cmr460.pdf

    NJ: N.J. Admin. Code § 8:51A-2.2

    NY: N.Y. Comp. Codes R. & Regs. tit. X, § 67-1.2, https://www.health.ny.gov/regulations/nycrr/title_10/part_67/#sec67-1-2

    RI: 23 24.6 PB R.I. Code R. § 3.1(b), http://sos.ri.gov/documents/archives/regdocs/released/pdf/DOH/7741.pdf

    VT: “Vermont Blood Lead Testing and Reporting Rule, 10-044, http://www.healthvermont.gov/regs/documents/lead_blood_testing_rule.pdf; Vermont Department of Public Health, “Blood Lead Screening Guidelines,” accessed October 21, 2016, http://healthvermont.gov/enviro/lead/screening.aspx

  44. We consider Connecticut to require testing around ages 1 and 2 because the testing is required annually from 9 months through 35 months, so it is likely to happen around 1 and 2, and the binding Guidance document says most providers test at 12 and 24 months.
  45. The only universal testing states that do not require additional testing are Iowa and Louisiana. Louisiana does require the administration of a risk assessment, but does not specify whether a test is required or just recommended on a positive answer.
  46. 16-4459A Del. Admin. Code, http://regulations.delaware.gov/AdminCode/title16/Department%20of%20Health%20and%20Social%20Services/Division%20of%20Public%20Health/Health%20Systems%20Protection%20(HSP)/4459A.shtml
  47. Md. Code Regs. 10.11.04.02B(2), .04 http://www.dsd.state.md.us/comar/SubtitleSearch.aspx?search=10.11.04.*
  48. One explanation for a percentage over 100 is that children moved into the state after 2009, so there were more children to be tested than the number born in 2009. Also, staff mentioned that they recently combined a large number of databases into one, and a small amount of duplication still exists.
  49. For sources, see notes under Tables 1.A – 1.D above.
  50. Iowa Admin. Code r. 641-67.5, http://idph.iowa.gov/Portals/1/Files/LPP/Chapter.641.67.pdf
  51. Michigan’s requirement only applies to children participating in the special supplemental food program for women, infants, and children (WIC). MO’s and WV’s requirements are in regulations but state lead program staff did not consistently refer to the policies as requirements. Although Maryland requires targeted screening for children born before 2015, since the state has universal screening for those born in and after 2015, it is not included in this tally.
  52. Staff in the West Virginia Office of Maternal, Child and Family Health, Childhood Lead Poisoning Prevention Program, Personal Communication, June 30, 2016
  53. E.g. – “shall test” in 410 Ill. Comp. Stat. § 45/6.2, http://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=1523&ChapterID=35 v. “A blood lead test should be performed” in Illinois Department of Public Health, “Childhood Lead Risk Questionnaire,” October 2015, http://idph.prod.acquia-sites.com/sites/default/files/forms/childhood-lead-risk-questionaire-and-guidelines-042116.pdf
  54. See Table 1.C for a list of states
  55. See http://www.health.pa.gov/My%20Health/Infant%20and%20Childrens%20Health/Lead%20Poisoning%20Prevention%20and%20Control/Documents/Lead%20Poisoning%20FAQs_042516_FINAL.pdf, accessed from here, under “Quick Links” – http://www.health.pa.gov/My%20Health/Infant%20and%20Childrens%20Health/Lead%20Poisoning%20Prevention%20and%20Control/Pages/default.aspx#.WAmVHZMrKb9 (last visited October 21, 2016)
  56. Available at http://epibulletins.dhss.alaska.gov/Document/Display?DocumentId=70, confirmed in a June 8, 2016 email from staff in the State of Alaska Department of Health and Social Services.
  57. Clark County, referenced here: Southern Nevada Health District, “Reportable Diseases and Conditions,” accessed October 21, 2016, https://www.southernnevadahealthdistrict.org/disease-reporting/disease-reporting.php
  58. N.H. Rev. Stat. Ann. § 130-A:5-b, http://www.gencourt.state.nh.us/rsa/html/X/130-A/130-A-5-b.htm
  59. HB 1917 (Session 2015), introduced in the Pennsylvania House of Representatives by Representative Cruz and referred to the Health committee on April 1, 2016, would require universal lead testing in the state and require insurance companies to pay for it, http://www.legis.state.pa.us/cfdocs/billInfo/billInfo.cfm?syear=2015&sind=0&body=H&type=B&bn=1917
  60. South Dakota and Wyoming. South Dakota’s website is comprised of laboratory-related and CDC-maintained information (https://doh.sd.gov/lab/medical-microbiology/lead.aspx)
  61. Arkansas Department of Health staff, Telephone interview, Late May/June 2016; Wyoming Department of Health staff, Telephone interview, Late May/June 2016
  62. North Dakota Health Department staff, Telephone interview, June 2016
  63. The only states that did not follow this part of the requirement (but did require tests at 12 and 24 months) were Maine, Mississippi, Nevada, New Mexico, Pennsylvania, Oregon, and Wyoming. New Mexico Medicaid staff confirmed by email that testing after 24 months was based on risk assessment, but the state’s lead program website said this testing was required if there was no previous test, without mentioning a risk assessment. New Mexico CLPPP, “Childhood Lead Poisoning Prevention Program,” accessed October 21, 2016, https://nmhealth.org/about/erd/eheb/clppp/. South Carolina’s Medicaid Provider Manual said children older than 24 months up to 6 years should be tested without a record of a previous test, but staff said the testing in this age period is “needed” where the doctor doesn’t know if it was done earlier. South Carolina Department of Health and Human Services staff, Personal communication, July 20, 2016. Kentucky’s requirement was unclear. Kentucky Department for Medicaid Services, “EPSDT Screening Services and EPSDT Special Services Policies and Procedures,” May 1998, http://www.chfs.ky.gov/NR/rdonlyres/64EFF098-5C67-48B4-8B8B-97EE2E9005BF/0/1034.pdf; See p. 4-10, stating that lead tests are required on positive answers to the risk assessments, but the relevant risk assessment question, on Appendix V, p. 1, is “Has your child ever had a blood lead test?”
  64. See fn32
  65. See fn33
  66. Pennsylvania Department of Human Services staff, Telephone interview, July 26, 2016
  67. Wisconsin Department of Health Services, “2014 Report on Childhood Lead Poisoning in Wisconsin,” January 2016, p. 14, https://www.dhs.wisconsin.gov/publications/p01202.pdf
  68. Utah Department of Health, Bureau of Managed Care; Personal communication; July 28, 2016
  69. “Updated Recommendations on Blood Lead Screening for Medicaid-Eligible Children,” State of Alaska Epidemiology Bulletin, January 21, 2010, http://www.epi.alaska.gov/bulletins/docs/b2010_01.pdf; confirmed to be current policy: Department of Health & Social Services staff, Telephone interview, June 10, 2016
  70. Montana DPHHS, “General Information for Providers,” August 2016, p. 3.4 (page updated January 2016), http://medicaidprovider.mt.gov/Portals/68/docs/manuals/General/GeneralManual08012016.pdf
  71. Neb. Admin. Code, ch. 33, § 002.02D.4, http://www.sos.ne.gov/rules-and-regs/regsearch/Rules/Health_and_Human_Services_System/Title-471/Chapter-33.pdf; Neb. Rev. Stat. § 71-2518(1)(a)(ii), http://nebraskalegislature.gov/laws/statutes.php?statute=71-2518
  72. Nebraska Dept. of Health & Human Services staff, Personal communication, October 18, 2016
  73. See fn67, at p. 24. By email dated July 29, 2016, staff said they planned to distribute reports again this year, likely because of renewed grant funding.
  74. Louisiana Healthy Homes and Childhood Lead Poisoning Prevention Program staff, Personal communication, July 25, 2016
  75. New Jersey Department of Health staff: Telephone interview, June 29, 2016 & Personal communication, August 8, 2016
  76. Massachusetts Department of Public Health staff, Telephone interview, June 28, 2016
  77. Connecticut Department of Public Health, Personal communication, July 22, 2016
  78. Rhode Island Department of Health, “Frequently Asked Questions about KIDSNET,” January 2011, http://www.health.ri.gov/publications/frequentlyaskedquestions/KIDSNET.pdf
  79. Rhode Island Department of Health, Personal communications, July 7, 2016 & July 21, 2016
  80. Kollett-Almeida, Michelle et al., “CDC Site Visit, June 2016,” Rhode Island Department of Health, p. 23.
  81. See fn67, at p. 24
  82. Id. at pp. 24-25. As of July 2016, staff planned to distribute reports again this year, likely because of renewed grant funding. Wisconsin Childhood Lead Poisoning Prevention Program staff, Personal communication, July 29, 2016
  83. North Carolina Department of Health and Human Services staff, Personal communication, July 16, 2016
  84. This is not an exhaustive list. State laboratories other than those in Michigan and Rhode Island may charge more or less. Michigan: $11, http://www.michigan.gov/mdhhs/0,5885,7-339-71550_2955_2983-19536–,00.html; Rhode Island: $25, p. G-1, http://sos.ri.gov/documents/archives/regdocs/holding/DOH/MasterFeeSchedule_PublicHearingDraft_September%202016.pdf. The range in the 2015 Maryland Lead Targeting Plan is similar: $14-$25 based on low and high Medicaid reimbursement, p. A-43, http://phpa.dhmh.maryland.gov/IDEHASharedDocuments/MD%202015%20Lead%20Targeting%20Plan.pdf. Lake County Health Department in Illinois charged up to $43 for a lead test as of 2010. American Academy of Pediatrics Illinois Chapter, “Lead Poisoning Blood Test Locations in Illinois,” July 21, 2010, http://illinoisaap.org/2010/07/lead-poisoningblood-test-locations-in-illinois/. A New Hampshire study reported that a test and venous blood draw averaged $38. Chawla, Chiahui, NH Department of Health and Human Services, “Economic Burden of Environmentally Attributable Illness in Children of New Hampshire,” July 2014, p. 20, https://www.nh.gov/epht/documents/nhchildrenreport.pdf
  85. U.S. Department of Health & Human Services Assistant Secretary for Public Affairs, “Preventive Services Covered Under the Affordable Care Act,” content last reviewed September 27, 2012, http://www.hhs.gov/healthcare/facts-and-features/fact-sheets/preventive-services-covered-under-aca/
  86. Bright Futures/American Academy of Pediatrics, “Recommendations for Preventive Pediatric Health Care,” Footnote 20, https://www.aap.org/en-us/Documents/periodicity_schedule.pdf
  87. See pub. 2 in fn25. For example: this interpretation would likely mean that for children 12 and 24 months old, ACA covers the tests required by Missouri regulations for these children spending over 10 hours in a high-risk area. (although Missouri requires tests annually from 6 months to 72 months for this population). ACA would also cover the state-required testing on a positive answer to a risk assessment, since the periodicity schedule recommends testing in this situation. Mo. Code Regs. tit. 19, 20-8.030 (3)
  88. LA: Lagarde, Gina, “UNIVERSAL Blood Lead Screening of Children under 6 years of Age,” Louisiana Childhood Lead Poisoning Prevention Program, October 23, 2008, https://www.lmmis.com/provweb1/children_lead.pdf;MD: Maryland Department of Health and Mental Hygiene, “Maryland Targeting Plan for Areas at Risk for Childhood Lead Poisoning,” October 2015, p. 1,
    http://phpa.dhmh.maryland.gov/IDEHASharedDocuments/MD%202015%20Lead%20Targeting%20Plan.pdf
  89. DE: 16-4459A, 2.0 Del. Admin. Code (see reference to zip codes),
    http://regulations.delaware.gov/AdminCode/title16/Department%20of%20Health%20and%20Social%20Services/Division%20of%20Public%20Health/Health%20Systems%20Protection%20(HSP)/4459A.shtmlMA: 105 Mass. Code Regs. 460.050(C)(2), http://www.mass.gov/courts/docs/lawlib/104-105cmr/105cmr460.pdf
  90. Kaiser Family Foundation, “2016 Employer Health Benefits Survey,” September 14, 2016, http://kff.org/report-section/ehbs-2016-summary-of-findings/
  91. New Jersey Department of Health staff, Telephone interview, June 29, 2016
  92. Chen MD, Harry, “Lead Poisoning Prevention: Report on 2015 Program Outcomes and Activities,” April 15, 2016, p. 11, http://legislature.vermont.gov/assets/Legislative-Reports/Lead-Poisoning-Prevention-4.15.16.pdf; Idaho Department of 40 October 2016 Health and Welfare, “Idaho Medicaid Lead Testing Program,” accessed October 21, 2016, http://healthandwelfare.idaho.gov/Medical/Medicaid/MedicalCare/LeadTestingProgram/tabid/692/Default.aspx
  93. New Jersey Department of Health, Personal communication, August 8, 2016
  94. Pennsylvania may require this in the future. Pennsylvania Department of Health, Personal communication, June 30, 2016
  95. DC: D.C. Code § 38-602(a-1), https://beta.code.dccouncil.us/dc/council/code/sections/38-602.htmlDE: 16 Del. C. § 2603, http://delcode.delaware.gov/title16/c026/index.shtml

    IA: Iowa’s universal testing requirement is that children entering kindergarten be tested – Iowa Admin. Code r. 641-67.5, .6, http://idph.iowa.gov/Portals/1/Files/LPP/Chapter.641.67.pdf

    IL: 410 Ill. Comp. Stat. § 45/7.1, http://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=1523&ChapterID=35

    MD: Md. Code Regs. 10.11.04.05, 10.11.02.B(17)(b), http://www.dsd.state.md.us/comar/SubtitleSearch.aspx?search=10.11.04.*, Maryland Code Family Law Article 5-556.1, http://mgaleg.maryland.gov/webmga/frmStatutesText.aspx?article=gfl&section=5-556.1&ext=html&session=2015RS&tab=subject5

    MA: 105 Mass. Code Regs. 460.050(E), http://www.mass.gov/courts/docs/lawlib/104-105cmr/105cmr460.pdf

    MO: Mo. Code Regs. tit. 19, 20-8.030 (9), http://s1.sos.mo.gov/cmsimages/adrules/csr/current/19csr/19c20-8.pdf

    NY: N.Y. Comp. Codes R. & Regs. tit. X, § 67-1.4, https://www.health.ny.gov/regulations/nycrr/title_10/part_67/#sec67-1-4

    RI: 23 24.6 PB R.I. Code R. § 3.1(d), http://sos.ri.gov/documents/archives/regdocs/released/pdf/DOH/7741.pdf

  96. Meriden and Waterbury, according to a July 22, 2016 email from staff in the Connecticut Department of Public Health. California’s school entry health exam report, required for first grade, includes a spot for a lead test. However, state staff via email on July 21, 2016 said this was not a “specific requirement.”
  97. Delaware Health and Social Services Department Division of Public Health, “Frequently Asked Questions: Regulations Governing the Childhood Lead Poisoning Prevention Act for Children Between the Ages of 22 and 26 Months,” accessed November 4, 2016, answer to question 3, http://www.dhss.delaware.gov/dhss/dph/hsp/files/olppscreenfaq.pdf; Meriden, Connecticut Health Department staff, Telephone interview, July 2016; Waterbury, Connecticut Health Department staff, Telephone interview, July 2016
  98. NY Department of Health, “What Child Care Providers Need to Know About Lead,” July 2009, https://www.health.ny.gov/publications/2517.pdf
  99. DC Office of the State Superintendent of Education Staff, Telephone interview, August 1, 2016
  100. Iowa Department of Public Health staff, Personal communications, July 1, 2016 and July 7, 2016
  101. Meriden, CT Health Department staff, Telephone interview, July 2016
  102. Delaware Lead Poisoning Prevention Program staff, Personal communication via Freedom of Information Act, August 5, 2016
  103. Cal Health & Safety Code § 105305: “The program implemented pursuant to this chapter shall be fully supported from the [Childhood Lead Poisoning Prevention] fees,” http://www.leginfo.ca.gov/cgi-bin/displaycode?section=hsc&group=105001-106000&file=105275-105310; California State Board of Equalization, “Childhood Lead Poisoning Prevention Fee,” accessed October 21, 2016, https://www.boe.ca.gov/sptaxprog/childhood_lead_poison_prev_fee.htm
  104. California State Board of Equalization, “Childhood Lead Poisoning Prevention Fee – FAQs,” accessed October 21, 2016, https://www.boe.ca.gov/sptaxprog/childhood_lead_poison_prev_fee_faq.htm
  105. E.g.: Minnesota’s screening guidelines (recommendations) have been endorsed by major medical groups. Minnesota Department of Health, “Guidelines,” accessed October 21, 2016, http://www.health.state.mn.us/divs/eh/lead/guidelines/#protect
  106. This total includes Alabama, where it is likely that doctors ask questions to determine risk of lead exposure before testing. Frostenson, Sarah, “America does a terrible job tracking how many kids have lead poisoning,” Vox, February 5, 2016. Current staff could not comment. This total did not include states where the use of questionnaires was optional.
  107. These questions are based on the Arizona, Nebraska, and Oregon questionnaires
  108. Cal. Code Regs. tit. 17, § 37020, 37100, http://www.cdph.ca.gov/programs/CLPPB/Pages/CACodeofRegsfull-CLPPB.aspx
  109. Nevada Department of Health and Human Services staff, Telephone interview, July 19, 2016
  110. See pub. 1 in fn 23, at p. 19-20
  111. Schwab, Lea T., et al., “Inaccuracy in Parental Reporting of the Age of Their Home for Lead-Screening Purposes,” Arch Pediatr Adolesc Med. 2003;157(6):584-586. doi:10.1001/archpedi.157.6.584, http://jamanetwork.com/journals/jamapediatrics/fullarticle/481353
  112. Dyal, Brenda, “Are lead risk questionnaires adequate predictors of blood lead levels in children?,” Public Health Nursing, 2012 Jan-Feb;29(1):3-10, p. 6 and Table 3, http://www.ncbi.nlm.nih.gov/pubmed/22211746. Limitations of the Dyal study included the small sample size (69 children) and not knowing where the questionnaire was administered (e.g. pediatrician’s office or Head Start program) or by whom.
  113. The study also briefly discussed shortcomings with the other common method of detecting lead exposure, zip code mapping. This method doesn’t account for people moving around and using imported toys or other items.
  114. An exception is Illinois: staff can check school records to see if questionnaires were administered but it’s unclear how often they do this. IL Department of Public Health Staff, Personal communication, July 1, 2016
  115. Md. Code Regs. 10.11.04.02 & .04, http://www.dsd.state.md.us/coma/SubtitleSearch.aspx?search=10.11.04.*; Maryland Department of Health and Mental Hygiene, “Maryland Targeting Plan for Areas at Risk for Childhood Lead Poisoning,” October 2015,
    http://phpa.dhmh.maryland.gov/IDEHASharedDocuments/MD%202015%20Lead%20Targeting%20Plan.pdf; See also: Maryland Department of Health and Mental Hygiene, “What is new in Lead Poisoning prevention in Maryland?” accessed October 21, 2016, http://phpa.dhmh.maryland.gov/OEhfp/eh/Pages/Lead.aspx
  116. See pub. 2 in fn115 at page 3
  117. Id. at Table 2 and Appendix 5
  118. Id. at p. 9
  119. MD DHMH estimated the cost of universal testing, follow-up testing for those with elevated levels, and further actions including home inspections for children with levels at or above 10 µg/dL as between $3.9 million and 5.9 million. This range reflects the potentially different cost per test, ranging from about $14 for a capillary test to $25 for a venous test. Id. at Tables A-5.1 and A-5.4, and p. A-50.
  120. Id. at p. 10.
  121. Ibid. The costs of long-term health effects and behavioral problems like osteoporosis and ADHD are assumed to be high, but are difficult to quantify at this time so are not included. The range in the estimate is due to different assumptions for how much BLLs impact IQ levels. Intangible costs of crime (suffered by victims) are included only in the upper limit. Id. at p. A-68, A-71 and A-72
  122. Id. at p. A-72
  123. At visits where testing is already required, risk assessments are important for identifying specific sources of lead exposure. Maryland requires doctors to administer the risk assessment to decide whether to test children at visits other than the 12- and 24-month visits if they were born on or after January 1, 2015 or born before 2015 but have lived in an at-risk area as defined in the 2004 state targeting plan. Id. at Appendix 1. For children who were born before 2015 and live outside 2004-designated at-risk areas, the state still requires risk assessments at the 24-month visit to determine whether any testing is indicated. Md. Code Regs. 10.11.04.03
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