Lead Testing for Children Enrolled in Medicaid

Download this report as a PDF >>

Lead exposure remains a public health issue, particularly for its harmful effects on children’s health. The primary sources of lead exposure continue to be from household hazards such as chipping paint and contaminated soil. It remains a risk to Washington children despite state and federal efforts to reduce it.

Washington tested a lower percentage of children overall than other western states, yet it had a higher percentage of children with elevated blood lead levels. In addition, Medicaid (in Washington called Apple Health) requires that all enrolled children should be tested for lead exposure. More than 240,000 of Washington’s 2.3 million Medicaid enrollees are under the age of 6. These children must receive blood lead screening tests at the ages of 12 months and 24 months. In addition, any child between 24 and 72 months with no record of a previous blood lead screening test must receive one.

Two state agencies – Health Care Authority and Department of Health – play key roles in mitigating lead exposure risks. As the state Medicaid agency, HCA is responsible for ensuring the state meets all federal program requirements. DOH is responsible for administering the Centers for Disease Control and Prevention’s Childhood Lead Poisoning Prevention Program. Both agencies have advocated for focusing blood lead testing only on children who have been identified as having one or more risk factors. However, the agencies have not received federal approval to use this approach.

Read a two-page summary of the report.

Report Number 1033619 Report Credits

Key results

Overall, only 26 percent of these children received at least one of the federally required tests between 1 year and 6 years old. This low testing rate increases the risk that some will not get the follow-up care they need.

Despite those low statewide testing rates, there are positive findings in this report. We identified two counties that test more than half the enrolled children in their area. Community outreach seems to improve testing rates. We found that children who did not speak English were tested at nearly twice the rate of native English speakers.

Importantly, state agencies have the tools and data they need to increase the number of children screened for lead exposure.

Background

Using data from 2015 through 2022, we matched two agency data sources to identify Medicaid-enrolled children who had been tested twice – at both 12 and 24 months old (the full Medicaid requirement) – and those who had been tested at least once between 12 and 72 months old (the minimum Medicaid standard). Our analysis included data on two groups of children:

  1. A group of 6-year-olds – children born between 2014 and 2016. Purpose: to evaluate the state’s compliance with the full Medicaid requirement, which goes up to a child’s sixth birthday.
  2. A group of 3-year-olds – children born between 2017 and 2019. Purpose: to determine how many children had been tested at 12 and 24 months old in recent years.

Note that the audit did not examine lead testing activities or results in Washington generally. Also, our analysis only includes test results that medical facilities in Washington sent to DOH. It is possible facilities have not submitted all results.

Unless otherwise specified in the report, our analyses concern only children enrolled in Medicaid.

State has not tested as required

The audit found that only 26 percent of Medicaid-enrolled children received a test between their first and sixth birthdays. For these children, this met the minimum standard set by Medicaid. That standard states: at least one test by the child’s sixth birthday (72 months). Medicaid actually requires two tests, one at 12 months and one at 24 months. Only 3 percent of children had blood lead level tests at both these ages.

We analyzed data for all children up to age 6 who were enrolled in Medicaid for at least six months. For these children, we estimated at least 98,000 were not tested between 12 and 72 months.

We also found that lead testing rates varied significantly by county. We examined blood lead test results for the 3-year-old group across the state to see if different regions achieved better rates of testing. At the county level, blood lead testing rates varied widely. The rate of continuously enrolled children tested at least once between 12 and 36 months ranged between 2 percent and 55 percent

In addition, we analyzed data concerning the demographic characteristics of Medicaid-enrolled children. We found that testing rates were nearly twice as high for children whose families did not speak or write English. However, testing rates were lower for children affiliated with a tribe or who identified as American Indian.

Choosing data to analyze

States can understand the risks posed by lead exposure by analyzing test results at any of several levels. For example, data analysts might consider statewide, aggregated test results, review county or regional-level results, or select some other dataset.

We found that analyzing lead risks at the county level can mask community-level differences. Although Washington has multiple factors that can increase a child’s risk of lead exposure, most children with the highest risk have never been tested. Children in areas with a heightened risk were tested at higher rates; however, three-quarters were not tested at all. Some communities with higher numbers of elevated test results also test the fewest children. Overall, we found the state has not met the Medicaid testing requirement.

Problems in agency processes

The state lacks an adequate process to ensure children enrolled in Medicaid receive required blood lead testing. Data analysis at state agencies is insufficient to accurately assess lead testing rates of Medicaid-enrolled children. Without active data-sharing agreements, HCA and DOH cannot conduct thorough test analyses. Furthermore, HCA lacks adequate performance measures to monitor the state’s compliance with Medicaid’s lead testing requirement.

Additionally, HCA has not used its existing, federally required, performance measure to actively monitor or increase testing compliance. HCA’s contracts with managed care organizations (MCOs) also lack clear expectations and performance standards necessary for effective compliance with Medicaid blood lead test requirements.

Improving testing rates

To help improve test rates, the state could do more to ensure providers have a clear understanding of testing requirements. The audit found health care provider uncertainty about Medicaid lead test requirements has likely contributed to low testing rates. The state could do more to ensure providers receive clear, consistent messaging about Medicaid requirements. DOH’s efforts to promote testing could help the state coordinate testing and increase awareness of lead exposure risks.

In addition, we found that by increasing awareness about the benefits of point-of-care testing and health records systems prompts, the state could help clinics and providers improve their processes to help reduce barriers to lead testing.

Recommendations

We made a series of recommendations to DOH and HCA to ensure children served by Medicaid in Washington receive required tests. Our recommendations fall into two main categories:

  • Implementing a monitoring process to identify children who have not received a blood lead test
  • Creating clear and consistent guidance for providers