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California State Auditor Logo COMMITMENT • INTEGRITY • LEADERSHIP

Childhood Lead Levels

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

Report Number: 2019-105

Figure 2
Sources of Lead Exposure

A series of eight pictographs representing sources of lead exposure. From left to right, the top row includes pictographs for pre-1978 paint, ceramic dishware, imported foods and spices, and toys and jewelry. The bottom row includes pictographs for some remedies and cosmetics, water pipes, fishing weights, and bullets.

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Figure 3
California and the Federal Government Have Taken a Variety of Steps to Address Lead Poisoning

A vertical timeline from 1960 to 2020. On the left side of the timeline a bar graph shows how the lead level which the CDC considers to be elevated has decreased over time. This bar graph indicates that in 1960 the CDC considered a lead level of 60 micrograms to be elevated, but over time lowered that value as follows: 1970, 40 micrograms; 1975, 30 micrograms; 1985, 25 micrograms; 1991, 10 micrograms; 2012, 5 micrograms. The right side of the timeline lists a series of steps which California and the federal government have taken to address lead poisoning. The actions taken by the State are highlighted, while those taken by the federal government are not. Starting from the top are three federal actions. In 1970 the Environmental Protection Agency (EPA) is formed to, among other things, establish environmental protection standards and research the adverse effects of pollution. In 1975 EPA regulations begin requiring graduated reductions in the lead content of leaded gasoline. And in 1977 the Consumer Product Safety Commission bans residential lead-containing paint manufactured after February 27, 1978. Following these are three highlighted State actions. In 1986 the State Legislature creates the Childhood Lead Poisoning Prevention Program within the Department of Health Services (DHS). In 1991 the State Legislature requires DHS to adopt regulations for blood lead testing of children determined to be at risk for lead poisoning. And in 1992 the State Legislature requires DHS to survey a sample of schools for developing risk factors to predict lead contamination in public schools. Two more federal actions follow. In 1995 a Federal ban on lead in gasoline goes into effect, and in 1996 the EPA and Department of Housing and Urban Development issue congressionally-mandated regulations for the disclosure of lead-based paint hazards in most housing built prior to 1978 offered for sale or lease. The final highlighted state action indicates that in 2007 the State legislature renames DHS as the State Department of Health Care Services (DHCS) and creates the State Department of Public Health (CDPH). DHCS is the state agency administering the Medi-Cal program. Responsibility for the Childhood Lead Poisoning Prevention Program is transferred to CDPH.

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Figure 4
Local Prevention Programs Provide Case Management Services for Most Children With Elevated Lead Levels

A color-coded map of the 58 California counties and the three cities of Berkeley, Pasadena, and Long Beach. 47 of the counties are colored blue, while 11 are colored yellow. In addition, 16 of the blue counties and 9 of the yellow counties are outlined and hatched with black lines. The map's legend indicates that the blue counties are those where the local prevention program provides case management services, while the yellow counties are those where CDPH provides case management services. The black outlines and hatching indicate counties where CDPH provides environmental investigation services. (The local program provides environmental investigation services for all others.) A large blue box to the right of the map shows that that 97 percent of children up to age 21 with elevated lead levels live in areas of the State where local prevention programs provide case management services. A smaller yellow box indicates that the remaining three percent live in areas where CDPH provides case management services. The map shows some patterns, most notably that the areas where CDPH provides the environmental investigations services are mostly in the northern and eastern parts of the State. A note at the bottom of the figure describes how California has 61 local public health officers, one in each of the 58 counties, including the city and county of San Francisco, and in the cities of Berkeley, Long Beach, and Pasadena. Local prevention programs in Long Beach and Pasadena provide case management services and environmental investigation services. Berkeley provides case management services, but CDPH provides environmental investigation services in that city. A detailed list of the counties follows. Local prevention programs provide both case management and environmental investigations services in the following counties: Alameda, Butte, Contra Costa, Fresno, Humboldt, Imperial, Kern, Los Angeles, Madera, Marin, Monterey, Nevada, Orange, Placer, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Joaquin, San Luis Obispo, San Mateo, Santa Clara, Santa Cruz, Solano, Sonoma, Stanislaus, Sutter, Tehama, Tulare, and Ventura. Local prevention programs provide case management services, while CDPH provides environmental investigations services in the following counties: Amador, Calaveras, Colusa, Del Norte, El Dorado, Glenn, Lake, Lassen, Mariposa, Modoc, Plumas, Shasta, Siskiyou, Tuolumne, Yolo, and Yuba. CDPH provides both case management and environmental investigations services in the following counties: Alpine, Inyo, Merced, Mono, Napa, San Benito, Santa Barbara, Sierra, and Trinity. Finally, CDPH provides case management services, while local prevention programs provide environmental investigations services in the following counties: Kings and Mendocino.

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Figure 5
DHCS and CDPH Both Have Responsibilities Related to Lead Poisoning

A hierarchical diagram which shows that both DHCS and CDPH have oversight roles and responsibilities for providing services to children related to lead poisoning and prevention. The diagram is organized with DHCS on the left, and CDPH on the right, providing oversight of various other entities which provide services to a group of children illustrated at the bottom. The left side of the diagram shows that DHCS oversees the provision of health care for children in Medi-Cal, which are half the children illustrated. The line of oversight from DHCS branches into two methods of delivering care—fee-for-service and Medi-Cal managed care plans—which each oversee health care providers. Medi-Cal managed care plans cover most of the children in Medi-Cal. A caption below those children states that half of children in California are in Medi-Cal and are generally required to be tested at ages 1 and 2. The right side of the diagram shows that CDPH oversees the Childhood Lead Poisoning Prevention Program, which oversees local prevention programs, and which provides case management services for all children with lead poisoning, and is responsible for reducing lead in the environment. The diagram shows that CDPH's responsibilities in these areas extend to all the children illustrated, including those in Medi-Cal. A caption below states that children not in Medi-Cal receive lead tests based on their health care providers' risk evaluations. A note reminds the reader that, as Figure 4 shows, 97 percent of children up to age 21 in the State with elevated lead levels live in areas where local prevention programs provide case management services, and 3 percent live in areas where CDPH provides case management services.

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Figure 6
Without an Increase in the Lead Prevention Fee or a Reduction in Expenditures, the Lead Prevention Fund is Forecast to Deplete its Fund Balance in Fiscal Year 2021–22

A line graph with three lines showing the amounts in millions of dollars of the lead prevention program's total expenditures, total revenue, and fund balance from fiscal years 2018-19 through 2021-22. The amounts for fiscal years 2018-19 and 2019-20 are based on budgeted amounts, while those after are based on projected amounts. Yellow shading on the graph highlights the projected time period. The scale on the left side of the graph spans from minus 20 million dollars to 80 million dollars, and a gray horizontal line denotes zero. A black line represents the lead prevention program's total annual expenditures, which start at 35 million dollars at the beginning of fiscal year 2018-19, then increase to 44 million dollars, and then again to 45 million dollars by the end of fiscal year 2019-20. The line shows that the projected expenditures then taper off slightly to 42 million dollars by the end of fiscal year 2020-21, and then to 39 million dollars by the end of fiscal year 2021-22. Below the black line is a green line, which shows the lead prevention program's total revenue, which is about half the value of the expenses. This revenue remains constant at 21 million dollars during the entire period shown on the graph from fiscal year 2018-19 through 2021-22. A downward sloping red line shows the lead prevention program's fund balance decreasing rapidly from 70 million dollars at the beginning of fiscal year 2018-19, to 56 million dollars, and then to 33 million dollars by the end of fiscal year 2019-20. The projected balance of the fund continues to drop to 9 million dollars by the end of fiscal year 2020-2021, and then drops below zero to a projected balance of negative 12 million dollars by the end of fiscal year 2021-22.

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Figure 7
Most Children in Medi-Cal Do Not Receive All Required Lead Tests

A pie chart which shows whether children in Medi-Cal received all or some of their required lead tests. A caption of the top of the figure indicates that the chart represents 2.9 million eligible children in Medi-Cal ages 1 and 2 years from fiscal years 2009-10 through 2017-18. The pie chart has three colors—red, yellow, and green—and each color is further subdivided into two or three sections. About half the pie chart is red, showing that 1.4 million children were not tested. Callouts indicate that of these, 735 thousand were eligible at both ages 1 and 2, 395 thousand were eligible only at age 1, and 290 thousand were eligible only at age 2. About one quarter of the pie chart is yellow, showing that 740 thousand children were not fully tested. Of these, 475 thousand were tested at age 1 but not tested at age 2, and 265 thousand were not tested at age 1 but tested at age 2. Finally, a little more than one quarter of the pie chart is green, showing that 780 thousand children were tested. Of these, 440 thousand were tested at both ages 1 and 2, 200 thousand were eligible only at age 1, and 140 thousand were eligible only at age 2.

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Figure 8
Missed Lead Tests Are Concentrated in Certain Areas of the State Fiscal Years 2013–14 Through 2017–18

A map of California showing a scatter plot of where in the State are located the census tracts with the largest number of missed lead tests for children ages 1 and 2 enrolled in Medi-Cal from fiscal years 2013–14 through 2017–18. The circles on the scatter plot range in size as well as shades of purple. A legend below the map indicates that the smallest circles and lightest shade of purple represent census tracts with fewer than 20 missed tests. The next larger circles and darker shade of purple represent census tracts with 1000 missed tests, and larger circles and a darker shade represent census tracts with 2000 missed tests. The largest circle and darkest shade of purple represent a census tract with 3290 missed tests, which is located in Los Angeles County. The clustering of the circles on the map shows quite clearly that missed lead tests are concentrated in certain areas of the state, particularly urban areas. The largest clusters of circles, including many of the darkest circles, are located in southern California around the greater Los Angeles area, as well as San Diego. There are also many circles clustered in the Central Valley, as well as around the San Francisco Bay Area. Smaller clusters of circles are scattered throughout the State. Large portions of the eastern and northern areas of the State have very few circles. Two pullouts on the map draw attention to Los Angeles and Sacramento Counties. The pullout for Los Angeles County shows a map of an area southwest of downtown Los Angeles and highlights five census tracts with many missed tests. A caption indicates that 6086 required tests were missed in the five highlighted census tracts in Los Angeles County. The pullout for Sacramento County shows a map of an area northeast of downtown Sacramento and also highlights five census tracts with many missed tests. The caption indicates that 3821 required tests were missed in the five highlighted census tracts in Sacramento County. A note informs the reader that we present an interactive dashboard for viewing additional detail on missed lead tests at www.auditor.ca.gov/reports/2019-105/supplementalgraphics.html. Also, to protect the confidentiality of the individuals summarized in the data, we included only census tracts with at least the following information for children ages 1 and 2 enrolled in Medi-Cal: 21 required tests, one missed test, and one completed test.

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Figure 9
California’s Lead Testing Rate Trails That of Most Other States

A bar graph of children's lead testing rates for the 50 states, with highest rates at the top and the lowest rates at the bottom. A caption explains that the graph shows the percentage of children ages 1 and 2 continuously enrolled in Medicaid for 90 days or more who had at least one lead test. California ranks 31st with a testing rate of 36.1 percent, while the U.S. average, which is indicated by a vertical red line and a map of the country, is 44.9 percent. At the top of the chart, Pennsylvania ranks highest with a testing rate of 80 percent, followed by Vermont at 67 percent, Illinois at 66 percent, and Maryland at 64 percent. California at 36 percent ranks just below Hawaii at 38 percent, and just above Indiana at 33 percent. Idaho and North Dakota are at the bottom of the chart with testing rates of less than 1 percent. Testing rates for all 50 states in descending order follow: Pennsylvania 80.1 percent; Vermont 67.2 percent; Illinois 65.8 percent; Maryland 64.3 percent; Wisconsin 60.4 percent; Massachusetts 60.3 percent; Michigan 60.0 percent; New Jersey 59.3 percent; North Carolina 58.9 percent; Iowa 56.5 percent; Georgia 53.7 percent; Tennessee 52.5 percent; New Hampshire 51.2 percent; Texas 50.6 percent; Missouri 49.1 percent; Florida 48.9 percent; Minnesota 47.9 percent; Rhode Island 47.9 percent; West Virginia 46.5 percent; New York 46.3 percent; Virginia 46.2 percent; Ohio 44.5 percent; Oklahoma 42.3 percent; Nebraska 42.1 percent; South Carolina 41.5 percent; Kentucky 41.3 percent; Alabama 40.7 percent; Mississippi 39.3 percent; Louisiana 39.0 percent; Hawaii 38.4 percent; California 36.1 percent; Indiana 32.5 percent; Kansas 32.1 percent; Maine 29.3 percent; Colorado 25.6 percent; Arkansas 25.3 percent; Arizona 24.0 percent; New Mexico 20.7 percent; South Dakota 17.9 percent; Oregon 15.2 percent; Nevada 14.7 percent; Wyoming 14.5 percent; Washington 13.9 percent; Utah 12.4 percent; Montana 12.2 percent; Connecticut 11.4 percent; Delaware 6.4 percent; Alaska 6.0 percent; Idaho 0.1 percent; North Dakota 0.1 percent.

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Figure 10
Children With Elevated Lead Levels Are Concentrated in Certain Areas of the State
Fiscal Years 2013–14 Through 2017–18

A map of California showing a scatter plot of where in the State are located the census tracts with the largest number of children under age 6 with elevated lead levels from fiscal years 2013–14 through 2017–18. The circles on the scatter plot range in size as well as shades of pink. A legend below the map indicates that the smallest circles and lightest shade of pink represent census tracts with 1 child with elevated lead levels. The next larger circles and darker shade of pink represent census tracts with 50 children with elevated lead levels, and larger circles and a darker shade represent census tracts with 100 children with elevated lead levels. The largest circle and darkest shade of pink represent a census tract with 153 children with elevated lead levels, which is located in Sacramento County. The clustering of the circles on the map shows quite clearly that children with elevated lead levels are concentrated in certain areas of the state, particularly urban areas. The largest clusters of circles, including many of the darkest circles, are located in southern California around the greater Los Angeles area, as well as San Diego. There is also a prominent cluster of dark circles in Sacramento. There are also many circles clustered in the Central Valley near Fresno, as well as around the San Francisco Bay Area, and a noticeable cluster along the north coast near Humboldt. Smaller clusters of circles are scattered throughout the State. Large portions of the eastern and northern areas of the State have very few circles. Two pullouts on the map draw attention to Los Angeles and Sacramento Counties. The pullout for Sacramento County shows a map of an area northeast of downtown Sacramento and highlights five census tracts with many children with elevated lead levels. A caption indicates that 389 children with elevated lead levels are located in the five highlighted census tracts in Sacramento County. The pullout for Los Angeles County shows a map of an area southwest of downtown Los Angeles and also highlights five census tracts with many children with elevated lead levels. The caption indicates that 205 children with elevated lead levels are located in the five highlighted census tracts in Los Angeles County. A note informs the reader that we present an interactive dashboard for viewing additional detail about children with elevated lead levels at www.auditor.ca.gov/reports/2019-105/supplementalgraphics.html. To protect the confidentiality of the individuals summarized in the data and to present census tracts consistent with Figure 8, we included only census tracts with at least the following information for children ages 1 and 2 enrolled in Medi-Cal: 21 required tests, one missed test, and one completed test.

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Figure 11
Thousands of Children With Elevated Lead Levels Did Not Receive
Follow-Up Lead Tests or Received Them Late
Fiscal Years 2013–14 Through 2017–18

A donut graph which shows whether 9148 children with elevated lead levels who should have received a follow-up lead test received their follow-up tests on time, late, or not at all. The donut graph has three colors—red, yellow, and green. The green portion of the graph shows that 5238 children, or 57 percent of the children with elevated lead levels, received a follow-up test on time. The yellow portion of the graph shows that 2408 children, or 26 percent of the children with elevated lead levels, received a follow-up test late. The red portion of the graph shows that 1502 children, or 17 percent of the children with elevated lead levels, did not receive a follow-up test.

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Figure 12
CDPH Publishes a Pamphlet Describing Childhood Lead Exposure Risks, Effects, and Testing Requirements

A CDPH Pamphlet from April 2016 titled Blood Lead Testing Guidance. The top section of the pamphlet describes the importance of testing at-risk children for lead exposure and the need for appropriate follow-up testing, as well as some of the harmful effects of lead, including developmental delay and organ damage. A link to the CDC website is included. The middle section of the pamphlet describes childhood lead poisoning regulations for California providers caring for children. A table includes anticipatory guidance, blood lead testing requirements, and risk assessment procedures. A link to the CDPH website is included. The bottom portion of the pamphlet describes federal refugee guidelines for lead tests and includes a link to the CDC website.

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