Testimony of Colleen McCauley, Health Policy Director, PCCY

HB 97 – House Democratic Policy Committee – January 22, 2019

Thank you, Representative Isaacson and members of the House Democratic Policy Committee, for this opportunity to discuss the critical issue of how to protect more babies from being unnecessarily harmed by lead poisoning.  I’m Colleen McCauley, the Health Policy Director at Public Citizens for Children and Youth or PCCY, and we are a children’s policy and advocacy organization working to improve the lives and life chances of kids in southeast PA and beyond. I’ve been engaged in lead poisoning prevention activities for 17 years. I facilitated the coalition that drafted and successfully advocated for the passage of Philadelphia’s 2011 lead disclosure law requiring rental property owners to certify that their pre-1978 properties are free of lead hazards, and I currently convene the Lead Free Philly Coalition that is striving to make the current law more enforceable.  I’ve also participated in a number of state-level activities including the creation of the PA Department of Health’s Lead Elimination Plan.  And I’m a member of a Steering Committee of the National Center for Healthy Housing.  I’m also a nurse, a parent and a current home owner and previous renter of properties built before 1978.

I am grateful for your attention to this matter.  Pennsylvania ranks second in the nation behind New York State with the greatest number of children poisoned by lead with 9,366 kids poisoned in 2017.[一世]^,[ii] I understand the heart of HB79 is to require that a reasonable effort be made to have all babies in the Commonwealth tested for lead poisoning and to require health insurance companies to cover the cost. What’s important to note is that the state is the insurer for nearly 1 in 2 children in the Commonwealth – I’m referring to the children enrolled in Medicaid (1.2 million) and the Children’s Health Insurance Program or CHIP (180,000).  And as the insurer of these children, the state is mandated to ensure that they are tested for lead based on the Center for Medicaid and Medicare Services (CMS) guidelines – which calls for babies to be tested at 12 and 24 months – or more simply put, two tests before children turn three.[iii]  The problem is that too many of these kids for whom the state is already mandated to ensure get tested are not being tested even once.  For CHIP, on average 40% of targeted kids are not tested at all (with a range of 22-71% not tested across health plans)[iv] and 20% of targeted Medicaid kids are not tested at all (with a range of 15-25% across health plans)[v].  Regarding the share of kids being tested twice by age three, neither the CHIP nor Medicaid programs measure this, so the state doesn’t know if it is complying with CMS guidelines or not.

Because limited resources are available to address this issue, I urge you to first help ensure that the kids for whom testing is already mandated get tested because they are at highest risk for being poisoned.  The children at greatest risk for poisoning are children who live in poverty – and these are most of the nearly 1.4 million Pennsylvania kids enrolled in Medicaid and CHIP.  Poverty is key because the vast majority of children harmed in PA and across the nation are poisoned by lead-based paint hazards from their older homes that are in disrepair because their parents have low incomes and can’t afford to maintain their properties OR because they typically live in sub-standard rental properties that are not properly maintained.

In addition to poor children, minority children and children who are immigrants or whose parents are immigrant are also among kids at highest risk for being poisoned.[vi]  Here again, state data on whether these children are being tested is limited.  The State Department of Health reports that 11% of children tested are African American[vii], yet almost triple that number or 27% of children on Medicaid are African American. The State Department of Health doesn’t have any data on the share of Latinx children tested.

To increase the number of children mandated to be tested on Medicaid and CHIP, I recommend that you take the following steps:

First, amend HB97 to include the requirement that each Medicaid and CHIP health insurance plan annually report compliance with the CMS lead poisoning testing guidelines.

Second, require the PA Department of Health to provide more robust reporting on children tested – and children poisoned – and this is something we’ve been speaking with officials in the DOH about and some of these changes officials also identified and are already working on for the next report.  We recommend that reports include children’s: insurance type (Medicaid, CHIP, private coverage); race and ethnicity, and the source of poisoning (paint flakes, lead dust, soil, etc.).  We also recommend that DOH reports include maps of larger PA cities showing zip code or even census tract level data on the share of children tested once and twice for lead by age three.  The Philadelphia Department of Public Health, for example, has more recently begun publishing these maps which would provide critical tools for the state and municipalities to monitor progress, identify areas with low testing rates that may need more resources and areas with higher testing rates and best practices that could be replicated.  (See page 3 below for samples of these maps).

Once the state increases testing for the most at-risk kids on Medicaid and CHIP, then more resources could be allocated to expand mandated testing for children with private insurance – perhaps starting with municipalities where there is already a high share of kids with public health insurance because health care providers there are used to testing children AND where there is a high share of older properties built before 1978.  City health departments in Philadelphia and Pittsburgh, for example, have already established recommendations for health care providers to test all children at one and two years old.

When the state would move towards universal testing, I recommend any mandate put on private insurers to test children be equivalent to the CMS testing mandate.  I also recommend that for the purpose of measuring the number of kids tested, that the state collect data for the first lead test between the ages of 9 and 24 months and for the second test between the ages of 25 and 36 months.  I say this because many children are not tested exactly in their birthday month as the CMS guidelines require (i.e. at 12 and 24 months).  If the state were only to record lead tests during these few months of a child’s life, we’d miss lots of lead tests – and the Department of Health’s lead poisoning surveillance reports reflect this.  For example, in 2017, about 30% of all children tested were under one (0-11 months), another 30% were one year old (12 to 23 months) and yet another 30% were two years old (24 to 35 months).

It is important for the legislature, governmental departments and private entities to work together and take steps to increase lead poisoning testing among children and improve testing reporting.  As you know, however, testing children is a necessary intervention – but it’s not sufficient to actually reduce lead poisoning. Testing children’s homes and removing any identified lead hazards is the most meaningful strategy to move the Commonwealth toward decreasing this injurious health care condition that robs children of their full potential and increases state costs for health care, early intervention services, special education, juvenile justice and other related services.

With limited resources, PCCY believes the state should be investing most of its time and money in assisting low income property owners get lead hazards out of their older properties so children don’t get harmed in the first place.  There are a number of best practices and potential strategies to generate remediation funds, and I particularly urge the legislature to consider imposing an additional five cent tax on a gallon of paint to enable the creation of a designated remediation program.  PCCY and other partners would be happy to be a resource to explore a paint tax and other funding ideas.  Thank you for your time today.

–DOWNLOAD THE TESTIMONY HERE: Colleen McCauley- HB97 Testimony–

[一世] Pennsylvania Department of Health. (2018). 2017 Childhood Lead Surveillance Annual Report. Available at https://www.health.pa.gov/topics/Documents/Environmental%20Health/2017%20Childhood%20Lead%20Surveillance%20Annual%20Report.pdf.

[ii] Center for Disease Control and Prevention. (2018). Lead Screening Table by State 2012-2016. Available at https://www.cdc.gov/nceh/lead/data/national.htm.

[iii] Centers for Medicare & Medicaid Services. (2016). CMCS Informational Bulletin – Coverage of Blood Lead Testing for Children Enrolled in Medicaid and the Children’s Health Insurance Program. Available at https://www.medicaid.gov/federal-policy-guidance/downloads/cib113016.pdf.

[iv] Commonwealth of Pennsylvania Department of Human Services. (2018). Children’s Health Insurance Program HEDISâ 2017 Comprehensive Report. Available at https://www.chipcoverspakids.com/chip-resources/Documents/2017_chip_hedis_comprehensive_report.pdf.

[v] Centers for Medicare & Medicaid Services. (2018). EPSDT 2017 State Report. Available at https://www.medicaid.gov/medicaid/benefits/epsdt/index.html.

[vi] Robert Wood Johnson Foundation and Pew Charitable Trusts. (2017). 10 Policies to Prevent and Respond to Childhood Lead Exposure.  Available at https://www.pewtrusts.org/en/research-and-analysis/reports/2017/08/10-policies-to-prevent-and-respond-to-childhood-lead-exposure.

[vii] Pennsylvania Department of Health. (2018). 2017 Childhood Lead Surveillance Annual Report. Available at https://www.health.pa.gov/topics/Documents/Environmental%20Health/2017%20Childhood%20Lead%20Surveillance%20Annual%20Report.pdf.