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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


Audit Highlights . . .

Our audit of DHCS and CDPH’s efforts to detect and prevent lead poisoning in children revealed the following:

Results in Brief

Lead is a toxic metal found in the air, soil, and drinking water of some schools and homes that is highly damaging when absorbed into the body. Children younger than six years old are especially vulnerable to lead poisoning and its harmful effects, which can include decreased IQ. Nonetheless, millions of children who should have been tested for elevated lead levels have not received all of the tests they should have because the two agencies charged with preventing and detecting lead poisoning in California have failed to adequately accomplish the duties with which they have been entrusted. For the purpose of this report, we define an elevated lead level as the point at which a lead test indicates a child’s blood has reached or exceeded a concentration of 4.5 micrograms of lead per deciliter of blood (micrograms) and lead poisoning as the point at which a lead test indicates a child’s blood has reached a concentration of 9.5 micrograms or higher.  The California Department of Health Care Services (DHCS) has not met its responsibility to ensure that children enrolled in the California Medical Assistance Program (Medi‑Cal)—which DHCS oversees—receive tests to determine whether they have elevated lead levels. Similarly, the California Department of Public Health (CDPH), which is charged with the prevention and management of lead poisoning cases, has failed to focus on addressing lead hazards before children are exposed to them and has not met legislative requirements concerning lead poisoning.

Children enrolled in Medi‑Cal often have not received the medical tests needed to identify elevated lead levels even though the State mandates such testing. With limited exceptions, California requires that children enrolled in Medi‑Cal receive tests for elevated lead levels at the ages of one and two years. However, according to DHCS’ data, millions of children in Medi‑Cal did not receive the lead tests they should have. These data show 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. According to DHCS’ data, the rate of eligible children receiving all of the tests that they should have was less than 27 percent. Many of these children live in areas of the State with high occurrences of elevated lead levels, making the low testing rates even more troubling.

Despite such low rates, DHCS has only recently begun developing a performance standard for measuring whether managed care plans, the entities with which it contracts to provide health care for Medi‑Cal beneficiaries, are ensuring that children receive the required lead tests. DHCS is also developing an incentive program to increase payments to health care providers for each lead test they report administering. However, we are concerned by how long it may take these programs to influence lead testing rates. While it begins enforcing the new performance standard and making incentive payments, DHCS could also take more immediate action that may increase the number of children receiving required tests. Specifically, DHCS could require health care plans to identify children who have not received lead tests and remind their health care providers of the need to provide the tests—a method other states have successfully used to increase testing rates.

Like DHCS, CDPH has not adequately met its responsibilities to protect children from lead poisoning. Although state law requires CDPH to identify geographic areas at high risk for childhood lead exposure and publish an analysis of this information each year beginning in March 2019, CDPH had not yet done so as of October 2019. In addition, it failed to meet a statutory requirement to post on its website a list of certain census tracts in which children have tested positive for specified lead levels. An analysis we performed using CDPH’s data shows that the number of children with elevated lead levels varies significantly by geographic area. Specifically, from fiscal years 2013–14 through 2017–18, half of children with elevated lead levels were located in just 15 percent of the State’s census tracts.
Although CDPH is responsible for reducing the incidence of excessive lead exposure in children, its current efforts do not appear to align with preventing future instances of lead poisoning in those geographic areas in which children are at the greatest risk. Specifically, CDPH has not proactively identified such high‑risk areas and taken steps to abate lead risks in these locations. In fact, CDPH contracts with childhood lead poisoning prevention programs at local agencies (local prevention programs) to increase the testing of at‑risk children, to provide follow‑up services for children with lead poisoning, and to eliminate lead in the environment. However, it only requires these programs to monitor abatement in the homes of children who already have lead poisoning, even though that effort prevents future poisoning only in those specific homes. In addition, although CDPH claims that local prevention programs are reducing lead exposure in high‑risk areas through outreach, it could not demonstrate the effectiveness of this outreach.

CDPH has also not been proactive in managing the State’s Childhood Lead Poisoning Prevention Program. For example, in recent years, CDPH failed to meet several legislative mandates that could enable it and health care providers to better identify children who need testing for elevated lead levels. One such mandate requires CDPH to update the factors health care providers use to determine if children are at risk of lead exposure. In addition, CDPH has not taken steps to advocate for changing a state law that currently makes it optional for laboratories to report certain contact information with test results for children tested for elevated lead levels. This state law does not require the use of a unique identifier that would allow CDPH to effectively match lead tests with existing cases of lead poisoning. The fact that this information is missing from lead tests has contributed to CDPH’s backlog of unprocessed test results and impeded its ability to contact families and monitor lead poisoning cases. Finally, CDPH has allocated funding to local prevention programs based on a funding formula that uses outdated information on the number of children with lead poisoning in each jurisdiction. This funding formula has led to significant differences in the services that local prevention programs have been able to provide to children with lead poisoning.

Summary of Recommendations:


To support CDPH’s efforts to efficiently contact families and monitor lead test results, the Legislature should amend state law to require laboratories to report contact information and unique identifiers with children’s lead test results.


Because of the severe and potentially permanent damage that lead exposure can cause in children, DHCS should do the following:


To identify the highest priority geographical areas for using resources to alleviate lead exposure among children, CDPH should immediately complete and publicize an analysis of high‑risk areas throughout the State.

To ensure that local prevention programs’ outreach results in a reduced number of children with lead poisoning, CDPH either should require local prevention programs to demonstrate the effectiveness of their outreach or should analyze the cost‑effectiveness of approaches such as proactive abatement and require the local prevention programs to replace or augment their outreach to the extent that resources allow.

To better ensure that children with lead poisoning are identified and treated, CDPH should prioritize meeting legislative requirements, including updating the factors health care providers use to determine whether children are at risk of lead exposure.

To ensure a more equitable distribution of resources for treating children with lead poisoning, CDPH should update its allocation formula to take into account the most recent data for the number of children with lead poisoning in each jurisdiction.

Agency Comments

DHCS agrees with our recommendations, but its approach for implementing certain recommendations does not fully address the related findings. CDPH agreed or partially agreed with most of our recommendations. However, its proposed implementation plan does not sufficiently address several concerns described in our report.

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