II. Federal Testing Policies and Funding
Recommendations by the Centers for Disease Control and Prevention
Screening recommendations by the Centers for Disease Control and Prevention (CDC) have changed over time. In 1978, CDC recommended universal screening for all children from 9 months to 6 years, with a special emphasis on screening by risk factors such as living in poorly maintained housing.
By 1997, CDC recognized that outside the Medicaid population, fewer children had EBLLs and the risk for lead exposure varied depending on geographic location. In light of this, CDC recommended states look at local BLL data and risk patterns to develop targeted screening strategies for children at ages 1 and 2 (and from 36-72 months if not previously screened) to better identify children with elevated lead levels. Universal screening was recommended by the agency only for communities where at least 12% of the children had elevated lead levels or where at least 27% of the housing stock was built before 1950.
In 2012, CDC began using a “reference value” for blood lead concentrations to identify children with lead exposure. The level is currently 5 micrograms per deciliter (μg/dL), and is higher than the BLL of 97.5% of children aged 1 to 5 in the U.S. who were tested for lead. The reference value can be used to trigger follow-up testing and other actions like environmental investigations, and to target primary prevention efforts.
Previously, CDC had issued recommendations for various “levels of concern” to indicate EBLLs needing intervention; from 1991 to 2012, the level of concern was 10 μg/dL.
The Centers for Medicare & Medicaid Services (CMS) is the federal agency that administers Medicaid. CMS requires children receiving Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit to be tested for BLLs at 12 and 24 months, and between the ages of 36 months and 72 months if the children were not previously tested. There were no exceptions to this until 2012, when CMS aligned its position with 2009 CDC recommendations and began allowing states to request approval to conduct targeted testing of children enrolled in Medicaid if they could provide data showing that it would be more effective in identifying children with high BLLs.
CDC does not have authority to require any blood lead testing; the agency can only make recommendations on the topic. In 2009, CDC determined that the number of children with EBLLs had decreased over the years. The agency found that national data and state-level studies suggested this decrease was similar for Medicaid-enrolled children and for the general population. They concluded that Medicaid eligibility did not necessarily mean the child faced an increased risk for EBLLs. CDC also believed that state officials were better equipped to identify the risk factors most impacting BLLs in their states. In agreeing with CDC’s recommendation for data-driven targeted screening of Medicaid-enrolled children, CMS emphasized that states would be able to use their limited resources for the children most in need of screening.
In its June 2012 memorandum, CMS noted the importance of primary prevention to avoid exposure to lead in the first place, but lauded screening as “critically important for identifying children with elevated blood [lead] levels and referring them for” follow-up care.
According to CMS staff, CMS has authorized only Arizona to conduct targeted screening of Medicaid-enrolled children. At least a few more states – Washington state and Nevada – have applications pending for targeted testing. In the wake of the Flint crisis, the CMS targeted testing option has come under Congressional scrutiny.
CDC Funding of State Programs
In 2003, CDC required state health departments that it funded “to develop and implement strategic childhood lead poisoning elimination plans.” In Fiscal Year (FY) 2011, CDC’s program budget was around $30 million and it was able to give large grants to bolster strong state lead programs – the average state or city grant was around $500,000. However, CDC funding for state lead programs was sharply cut in FY2012 and FY2013. $11 million in grant funding, out of the program’s $15.5 million budget, became available in FY2014 and was awarded to 29 states, DC, and 5 cities. These programs have received an average award of between $250,000-$300,000/year, contingent on the availability of future funds, in 3-year cooperative agreements that end in August 2017.