News Coverage
State ignores law requiring lead testing for all Medicaid children
Published July 9, 2004
Federal law requires all children insured under Medicaid to be screened for lead poisoning, but Washington state has been ignoring the rule for years.
While some states such as Massachusetts screen all children, state officials and physicians here say blanket or even targeted screening isn't necessary given the low prevalence of lead poisoning in the state.
Children enrolled in Medicaid are considered at risk for lead poisoning and must be screened at 12 and 24 months, according to Medicaid rules adopted in 1989.
But last year, only several thousand -- or less than one-half of 1 percent -- of the 560,000 Washington children enrolled in Medicaid were tested.
A 1999 General Accounting Office report criticized Washington for failing to screen children on Medicaid, noting that health providers here didn't support testing "because lead poisoning is not viewed as a significant problem."
"Nobody here in our community thinks it's worthwhile," said Dr. Bill Robertson, a pediatrician and medical director of the Washington Poison Center. "The reason is very clear. ... It's scientifically absolutely ludicrous to abuse children with needle pokes when the frequency of (high lead blood) elevation is so low."
There is no medically proven treatment for low levels of lead poisoning.
Different states view lead poisoning with varying degrees of alarm, according to the GAO, the investigative arm of Congress.
Massachusetts reported that 3.7 percent of children screened had high blood lead levels and screened all children until 48 months. Meanwhile, Washington's lead registry shows that 3 percent of the children screened had elevated blood lead levels, but the state doesn't conduct routine screening,the report noted.
Washington relies on doctors to test children they suspect have been exposed to lead. The state's lead registry reports results of all tests conducted each year, a number Robertson says is inflated because the tests come from a higher risk population.
State health officials conducted a random survey in 1999 and found that 0.9 percent of 1- to 2-year-olds in the state have high blood lead levels, measured at 10 micrograms per deciliter or higher. Meanwhile, 3.8 percent of Hispanic children in Central Washington have high blood lead levels, and the state has supported increased screening in that area.
Many states don't test children on Medicaid, though "the requirement is clear," said Arianne Callender, general counsel for the Environmental Working Group, a non-profit research group.
In a report published earlier this year, the group estimated that 13,300 Ohio children were lead poisoned but weren't identified because of failures to screen.
Callender said the law is connected to federal funding, but she isn't aware of enforcement against states.
"The feds do know what our practice is and there has been discussion about it," said Jim Stevenson, communications director for the Medical Assistance Administration of the state Department of Social and Health Services.
"Our feeling is that it is not an evidence-based decision, and it should be a matter of clinical judgment," he said.
Stevenson said the lead-testing position has been guided by the state health policy, which leaves it up to the health provider's discretion.
The state doesn't have a waiver to exempt it from the rules.
Rod Haynes, spokesman for the regional district of Centers for Medicare and Medicaid Services, said there aren't civil penalties when states don't comply.
Callender, with the research group, said she doesn't understand how Washington can be so open about ignoring the federal law.
Massachusetts screens all children for lead poisoning. In 2001, New York City reported that 76 percent of children in Medicaid plans were screened for lead poisoning.
Children enrolled in Medicaid account for 60 percent of children found with elevated blood lead levels greater than 10 micrograms per deciliter, and 83 percent of children with elevated blood levels greater than 20, according to a 2000 CDC report.
What may be appropriate for other states, particularly on the East Coast where housing stock is much older, doesn't make sense for Washington, said Robertson.
"They do have lead poisoning out there," Robertson said. "Out here we simply don't have that."
The Academy of American Pediatrics supports targeted testing based on risks.
Between 2002 and 2003, 12,454 children -- from newborns to age 6 -- were tested in Washington state. Of those, 158 had elevated blood lead levels, or 1.2 percent.
Dr. Joel Kaufman said he initially was concerned about lead screening in the state.
But "at this point in time in Washington state, universal screening of children does not seem to be necessary, based on what we know about the prevalence of lead in children," said Kaufman, director of the University of Washington's Occupational and Environmental Medicine program and professor of environmental health and medicine.
Dr. Catherine Karr, a pediatrician and director of the pediatric environmental health specialty unit at UW, said the data indicate the state has less of a problem than the East Coast.
"Instead of pouring all of our resources into defining the right people to screen, the shift should be on primary prevention, taking lead out of our environment."