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Childhood Lead Levels

Millions of Children in Medi-Cal Have Not Received Required Testing for Lead Poisoning

Report Number: 2019-105

January 7, 2020

The Governor of California
President pro Tempore of the Senate
Speaker of the Assembly
State Capitol
Sacramento, California 95814

Dear Governor and Legislative Leaders:

As directed by the Joint Legislative Audit Committee, my office conducted an audit of the California Department of Health Care Services (DHCS) and the California Department of Public Health (CDPH). Our assessment focused on both the administration of lead tests to children in Medi-Cal and the activities of the Childhood Lead Poisoning Prevention Program, and the following report details the audit’s findings and conclusions. In general, we determined that millions of children in Medi-Cal are not receiving the lead tests they should be receiving, and CDPH is not prioritizing the prevention of lead poisoning.

State law generally requires that children enrolled in Medi-Cal receive tests for elevated lead levels at the ages of one and two years. When we reviewed data maintained by DHCS, we found that from fiscal years 2009–10 through 2017–18, more than 1.4 million of the 2.9 million one- and two-year-old children enrolled in Medi-Cal did not receive any of the required tests, and another 740,000 children missed one of the two tests. As a result, the rate of eligible children receiving all of the tests that they should have was less than 27 percent. Without these tests, health care providers do not know whether these children are suffering from elevated lead levels and need treatment. Despite low lead testing rates, DHCS has only recently begun developing an incentive program to increase testing and a performance standard for measuring the extent to which managed care plans are providing the tests.

We also found that CDPH, which manages the State’s Childhood Lead Poisoning Prevention Program, does not focus on proactive abatement of lead hazards to prevent future poisoning. Instead, CDPH requires local childhood lead poisoning prevention programs (local prevention programs), to which it delegates many of its responsibilities, to monitor abatement in the homes of children who have already been poisoned. However, such efforts only prevent future poisoning in those specific homes. Although CDPH claims that the local prevention programs are reducing lead exposure through education and outreach, it could not demonstrate the effectiveness of this outreach. Finally, CDPH has failed to meet several legislative requirements, including a mandate to update the factors that health care providers must use to determine whether a child is at risk of lead exposure, which help them identify children who need testing.

Respectfully submitted,

California State Auditor