Existing law, the Childhood Lead Poisoning Prevention Act of 1991, requires the State Department of Public Health to adopt regulations establishing a standard of care at least as stringent as the most recent United States Centers for Disease Control and Prevention screening guidelines, whereby all children are evaluated for risk of lead poisoning by health care providers during each childs periodic health assessment. Existing law requires the standard of care for a child who is determined to be at risk for lead poisoning to include the screening of that child. Existing regulations require every health care provider who performs a periodic health assessment of a child to order a child who receives services from a publicly funded program for low-income children to be screened for lead poisoning.

This bill would require the department to coordinate with specified state entities to gather data to determine whether low-income children are being screened for lead poisoning as required by the regulation described above. The bill would also require all uses and disclosures of the gathered or shared data to comply with all applicable state and federal laws for the protection of the privacy and security of data.

Existing law requires a laboratory that performs a blood lead analysis on a specimen of human blood drawn in California to report specified information to the department for each analysis on every person tested. Existing law requires that all information reported be confidential, except that the department is authorized to share the information for the purpose of surveillance, case management, investigation, environmental assessment, environmental remediation, or abatement with the local health department, environmental health agency, or building department, so long as the entity receiving the information otherwise maintains the confidentiality of the information, as specified.

This bill would add the State Department of Health Care Services to the above-described list of entities with which the State Department of Public Health is authorized to share the reported information, for official governmental program purposes.

Existing law, the Childhood Lead Poisoning Prevention Act of 1991, requires the State Department of Public Health to adopt regulations establishing a standard of care at least as stringent as the most recent United States Centers for Disease Control and Prevention screening guidelines, whereby all children are evaluated for risk of lead poisoning by health care providers during each childs periodic health assessment. Existing law requires the standard of care for a child who is determined to be at risk for lead poisoning to be screened. include the screening of that child. Existing regulations require every health care provider who performs a periodic health assessment of a child to order a child who receives services from a publicly funded program for low-income children to be screened for lead poisoning.

This bill would require the department to coordinate with specified state entities to gather data to determine whether children are being screened for lead poisoning as required by the regulation described above.

Existing law, the Childhood Lead Poisoning Prevention Act of 1991, requires the State Department of Public Health to adopt regulations establishing a standard of care at least as stringent as the most recent United States Centers for Disease Control and Prevention screening guidelines, whereby all children are evaluated for risk of lead poisoning by health care providers during each childs periodic health assessment. Existing law requires the standard of care for a child who is determined to be at risk for lead poisoning to be screened. Existing regulations require every health care provider who performs a periodic health assessment of a child to order a child who receives services from a publicly funded program for low-income children to be screened for lead poisoning.

This bill would require the department to coordinate with specified state entities to gather data to determine whether children are being screened for lead poisoning as required by the regulation described above.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Under existing law, Medi-Cal covers early and periodic screening, diagnosis, and treatment for individuals under 21 years of age, consistent with federal law.

This bill would require the department to ensure that a child enrolled in Medi-Cal receives blood lead screening tests at 12 and 24 months of age. The bill would also require the department to ensure that a child 2 to 6 years of age, inclusive, receives at least one blood lead screening test if there is no record of a previous test for that child.

SENATE COMMITTEE ON APPROPRIATIONS

Senator Anthony Portantino, Chair

2017 - 2018 Regular Session

AB 2976 (Quirk) - Childhood lead poisoning: prevention

This bill meets the criteria for referral to the Suspense File.

Bill Summary:

• Requires Department of Public Health (CDPH) to coordinate with the state entities, including Department of Health Care Services (DHCS), that are responsible for administering specified publicly funded programs to gather data to determine whether children are being screened for lead poisoning, as required pursuant to existing regulation.

Fiscal Impact:

• $316,800 (General Fund or special fund) ongoing for 2.0 full-time research scientist positions at CDPH that will gather, analyze, and report data to monitor screening rates for children in publicly funded programs for low-income children. The staff would process, track, monitor, and follow-up with cases.
• Approximately $150,000 for the DHCS (General Fund/federal fund) to continue current work on comparing Medi-Cal encounter data with CDPH case management system data.
• Depending on challenges with data-matching and if information technology solutions were needed, these costs could be lower or higher.

Background:

The California Department of Public Health (CDPH), under the Childhood Lead Poisoning Prevention Act of 1991, has regulations whereby all children are evaluated for risk of lead poisoning by health care providers during each child’s periodic health assessment. The Department of Health Care Services (DHCS) administers the state’s Medi-Cal program, which provides specified health services to qualified inividuals. Medi-Cal includes the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program for any individual under 21 years of age, consistent with the requirements of a specified EPSDT provision of federal Medicaid law. EPSDT services include screening, vision, dental, hearing and other diagnostic services, such as laboratory tests for blood lead level (BLL) assessment appropriate for age and risk factors. Currently, every health care provider who performs a periodic health assessment of a child at the ages below must comply with the following standard of care:

• Provide oral or written anticipatory guidance to a parent or guardian of the child, including, at a minimum, the information that children can be harmed by exposure to lead, especially deteriorating or disturbed lead-based paint and the dust from it, and are particularly at risk of lead poisoning from the time the child begins to crawl until 72 months of age;
• If the child receives services from a publicly funded program for low-income children, order the child screened for lead poisoning as the child is presumed to be at risk of lead poisoning; and,
• If the child does not receive services from a publicly funded program for low-income children, evaluate the child's risk of lead poisoning by asking a parent or guardian of the child the following question: “Does your child live in, or spend a lot of time in, a place built before 1978 that has peeling or chipped paint or that has been recently renovated?” If the parent or guardian answers “yes” or “don't know” to the question, order the child screened for lead poisoning.

The health care provider to perform the actions above at periodic health assessments, starting at six months of age and continuing until 72 months of age, and under other specified timeframes. As part of the model contract between DHCS and Medi-Cal managed care plans, plans must cover and ensure the provision of a blood lead screening test to children at 12 months and 24 months, and to document and appropriately follow up on blood lead screening test results. Any child enrolled in Medi-Cal between 24 and 72 months of age who did not receive a blood lead test at scheduled times must receive a blood lead test. Plans are also required to make reasonable attempts to ensure the blood lead screen test is provided and to document attempts to provide the test in the child’s medical record. Documentation is required to be entered in to the child’s medical record to indicate the receipt of blood lead screen testing and test results, of voluntary refusal of these services, or of nonresponse. In addition, existing CDPH regulations require all children enrolled in specified programs, such as Medi-Cal, Women, Infants, and Children (WIC), Supplemental Nutrition Assistance Program (SNAP), must also receive a blood lead test at 12 and 24 months of age. The costs of all blood lead test for children who receive public assistance are covered by the state.

Blood lead test results are reported electronically to the CDPH Childhood Lead Poisoning Prevention Branch and are stored in the Response and Surveillance System for Childhood Lead Exposures (RASSCLE) database. Aggregate information on increased blood lead levels reported to RASSCLE are extracted and provided to local lead prevention programs every other week, including the 43 contracted local jurisdictions that provide lead prevention services (the state provides direct services to the remaining 18 health jurisdictions).

AB 1316 (Quirk, Chapter 507, Statutes of 2017) requires DPH to revise its regulations for the Childhood Lead Poisoning Prevention Program (CLPP) to redefine the assessment of risks for the purposes of evaluating a child's risk for lead exposure. Requires DPH to consider the most significant risk factors for childhood lead exposure, as specified. Makes several technical and clarifying changes to the CLPP statute and the mandate on health care service plans that offer preventive services for children.

Proposed Law:

The bill includes the following provisions, among others:

• Requires that state entities that administer the publicly funded program for low-income children to electronically share data with the department, as needed, to enable the department whether low-income children are being screened for lead-poisoning, as required in regulations.
• Requires DPH to coordinate with the state entities, including DHCS, that are responsible for administering specified publicly funded programs to gather data to determine whether children are being screened for lead poisoning, as required pursuant to existing regulation.
• Requires that all uses and disclosures of data gathered or shared must comply with all applicable state and federal laws for the protection of the privacy and security of data.

Related Legislation:

• SB 1097 (Leyva) requires DPH’s report regarding the effectiveness of appropriate lead poisoning case management efforts to include additional data, including the number of children identified as being at risk who received blood testing. Requires the report to indicate whether the sources of lead poisoning described under this bill have been removed or abated. Requires DPH to post the report its Web site. Requires DPH to incorporate the data collected and the report into the Healthy Communities Data and Indicators Project, as specified. SB 1041 pending consideration in the Assembly Appropriations Committee.
• AB 11 (McCarty) requires that screening services available under the Early and Periodic Screening, Diagnostic and Treatment Program specifically include screening services for individuals zero to three years of age, inclusive, in compliance with the periodicity schedule and the standardized and validated screening tool that are established by the Bright Futures/American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care and by any future updates to those recommendations. AB 11 is on the Senate Appropriations Committee suspense file.
• AB 2122 (Reyes) establishes requirements for DHCS and Medi-Cal managed care plans to ensure children receive blood lead screening, information about lead exposure and testing and follow-up services for children with an elevated blood lead level, including a contractual requirement for plans and its contractors to meet the lead testing standard of care under federal Medicaid law. Establishes state goals for children at risk of lead exposure and for blood testing for children under age who are eligible for Medi-Cal. Requires DHCS to include blood lead screening tests as a performance measure in its annual External Accountability Set, and requires DHCS to annually create a report detailing the DHCS’ progress toward the state goals. Requires DPH to prepare provider training guidelines, curriculum, and resources that are required to be used to educate providers about childhood lead poisoning prevention, childhood lead exposure risks, childhood lead exposure health effects, and sources of childhood lead exposure at the state, regional, and local levels. AB 2122 is is on the Senate Appropriations Committee suspense file.

Staff Comments:

Staff notes that workload associated with the bill is what existing law requires, however, the cost of blood lead testing is covered by Medi-Cal and other health insurance, not CDPH. If a large number of children in publically funded programs are identified as not being tested as required, CDPH would be required to ensure those identified children receive the required testing. The required testing would result in a large number of tests then being reported to CLPPB, and a large increase in the number of children identified with increased levels of lead. Costs for blood level tests can vary depending upon the provider and payer.  Blood lead tests range from $25 - $200.

The two departments, DHCS and CDPH, can also utilize an existing Agency data use agreement to share information; however, the extent to which existing case management systems between both departments are shared is unknown at the time of the analysis.

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SENATE COMMITTEE ON HEALTH

Senator Dr. Richard Pan, Chair

BILL NO: AB 2976

SUBJECT: Childhood lead poisoning: prevention.

SUMMARY:

Requires the Department of Public Health to coordinate with the state entities, including the Department of Health Care Services, that are responsible for administering the publicly funded programs to gather data to determine whether children are being screened for lead poisoning, as required by pursuant to existing regulation.

Existing law:

1. Establishes the Medi-Cal program, administered by the Department of Health Care Services (DHCS), under which low income individuals are eligible for medical coverage. [WIC §14000, et seq.]
   
2. Makes children with incomes up to 266% of the Federal Poverty Level (FPL) eligible for Medi-Cal, including providing full-scope Medi-Cal benefits to undocumented children through age 18. [WIC §14005.26, and 14005.64]
   
3. Requires the governing body of each county to establish a community child health and disability prevention (CHDP) program for the purpose of providing early and periodic assessments of the health status of children in the county. Makes CHDP the responsibility of DHCS for all counties that contract with the state for health services. [HSC §124040]
   
4. Requires each CHDP plan to include, but is not limited to, specified requirements, including:
   
5. Health screening and evaluation services for all children, including a physical examination, immunizations appropriate for the child’s age and health history, and laboratory procedures appropriate for the child’s age and population group;
6. Referral for diagnosis or treatment when needed, including, for all children eligible for Medi-Cal, referral for treatment by a provider participating in the Medi-Cal program of the conditions detected, and methods for assuring referral is carried out;
7. A health and development history;
8. An assessment of physical growth;
9. An examination for obvious physical defects;
10. Ear, nose, mouth, and throat inspection, including inspection of teeth and gums, and for all children one year of age and older who are eligible for Medi-Cal, referral to a dentist participating in the Medi-Cal program;
11. Screening tests for vision, hearing, anemia, tuberculosis, diabetes, and urinary tract conditions;
12. An assessment of nutritional status;
13. An assessment of immunization status; and,
14. If appropriate, testing for sickle-cell trait, lead poisoning, and other tests that may be necessary to the identification of children with potential disabilities requiring diagnosis and possibly treatment. [HSC §124040]
15. Requires the Department of Public Health (DPH), under the Childhood Lead Poisoning Prevention Act of 1991, to adopt regulations establishing a standard of care, at least as stringent as the most recent federal Centers for Disease Control and Prevention (CDC) screening guidelines, whereby all children are evaluated for risk of lead poisoning by health care providers during each child’s periodic health assessment. [HSC §10528]
    
16. Requires, pursuant to state CHDP regulation, every health care provider who performs a periodic health assessment of a child, at the ages below to comply with the following standard of care:
17. Provide oral or written anticipatory guidance to a parent or guardian of the child, including, at a minimum, the information that children can be harmed by exposure to lead, especially deteriorating or disturbed lead-based paint and the dust from it, and are particularly at risk of lead poisoning from the time the child begins to crawl until 72 months of age;
18. If the child receives services from a publicly funded program for low-income children, order the child screened for lead poisoning as the child is presumed to be at risk of lead poisoning; and,
19. If the child does not receive services from a publicly funded program for low-income children, evaluate the child's risk of lead poisoning by asking a parent or guardian of the child the following question: “Does your child live in, or spend a lot of time in, a place built before 1978 that has peeling or chipped paint or that has been recently renovated?” If the parent or guardian answers “yes” or “don't know” to the question, order the child screened for lead poisoning. [17 CCR §37100]
20. Requires the health care provider to perform the actions at each of the following times:
21. Requires the anticipatory guidance required by 6a) to be performed at each periodic health assessment, starting at six months of age and continuing until 72 months of age.
22. The screening and evaluation required by 6c) to be performed:
23. When the child is 12 months of age;
24. When the child is 24 months of age;
25. Whenever the health care provider performing a periodic health assessment becomes aware that the child is 12 months to 24 months of age and the actions specified in 6b) and c) above were not taken at 12 months of age or thereafter;
26. Whenever the health care provider performing a periodic health assessment becomes aware that the child is 24 months to 72 months of age and the actions specified in 6b) and c) above were not taken when the child was 24 months of age or thereafter;
27. Whenever the health care provider performing a periodic health assessment of a child 12 to 72 months of age becomes aware that, in the professional judgment of the health care provider, a change in circumstances has put the child at risk of lead poisoning. [17 CCR §37100]
28. Prohibits a health care provider from having a duty to order a child screened for lead poisoning:
29. If a parent or guardian of the child, or other person with legal authority to withhold consent, refuses to consent to the screening; and,
30. If and so long as the risk of screening is a greater risk to the child's health than the risk of lead poisoning, in the professional judgment of the health care provider. [17 CCR §37100]
31. Makes a health care provider who fails to comply with this standard of care subject to the disciplinary provisions of the Medical Practice Act.
    
32. Requires a laboratory that performs a blood lead analysis on a specimen of human blood drawn in California to report specified information to the Department of Public Health department for each analysis on every person tested, including the test results in micrograms of lead per deciliter, the name of the person tested, the person’s birth date if the analyzing laboratory has that information, or if not, the person’s age, the person’s address, including the ZIP Code, if the analyzing laboratory has that information, or if not, a telephone number by which the person may be contacted, and the name, address, and telephone number of the health care provider that ordered the analysis. [HSC §124130]
    
33. Requires all information reported pursuant to 10) above to be confidential, as provided, except that DPH may share the information for the purpose of surveillance, case management, investigation, environmental assessment, environmental remediation, or abatement with the local health department, authorized environmental health agency authorized, or building department. [HSC §124130]

This bill:

1. Requires DPH to coordinate with the state entities, including DHCS, that are responsible for administering specified publicly funded programs to gather data to determine whether children are being screened for lead poisoning, as required pursuant to existing regulation.
   
2. Defines the specified publicly funded programs as follows:
   
3. Medi-Cal;
4. CHDP;
5. The Special Supplemental Nutrition Program for Women, Infants and Children (WIC); and,
6. Any federally funded or State of California funded program that provides medical services or preventive healthcare to children in families whose income is equal to or less than the maximum qualifying income level for participation in any of the programs specified above.

FISCAL EFFECT:

According to the Assembly Appropriations Committee, costs to DPH and DHCS, likely in the range of $150,000 for each department (General Fund (GF) for DPH; GF/federal for DHCS), to continue current work on comparing Medi-Cal encounter data with DPH case management system data. Depending on challenges with data-matching and if information technology solutions were needed, these costs could be lower or higher.

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, the Assembly Environmental Safety & Toxic Materials Committee (ESTM Committee) held an oversight hearing on February 13, 2018, to better understand the compliance rate for testing children for lead exposure who are enrolled in publicly funded programs for low-income. The ESTM Committee received data from DHCS, which shows that in the last five years, only about 37% of children ages one and two years old who have been continuously enrolled in Medi-Cal, have been annually blood lead tested. When receiving a child’s blood lead test result, the DPH does not obtain any information about whether or not the child is on a state assistance program. This makes it challenging to know how many children on Medi-Cal, and other covered programs, are being blood lead tested. Currently, DPH uses federal census data to determine how many children are in California and how many are living below the federal poverty line to determine how many children are likely on state assistance and therefore how many should be tested. This is a convoluted method for extrapolating a compliance status with the mandate. This "accounting" for compliance makes it difficult for DPH to make programmatic changes to test more children if compliance is inaccurate under its formula.

DPH and DHCS have never coordinated on childhood blood lead level data (BLL), so determining compliance or status with testing requirements has never been done. At the hearing, DHCS Director committed to coordinate with DPH to have more comparable data so that the two departments can see more easily how many children on Medi-Cal are currently being tested for lead exposure, and the Director has since reported a timeframe to ESTM Committee for getting that done. This bill would essentially codify the ‘partnership’ to coordinate on childhood blood lead data to determine compliance with the requirement that ALL kids at specified ages on Medi-Cal get lead tested. 

1. Background. According to the CDC, at least four million households include children that are being exposed to high levels of lead. Children are exposed to lead from different sources (such as paint, gasoline, solder, and consumer products like candy, artificial turf, and toys) and through different pathways (such as air, food, water, dust, and soil). Although there are several exposure sources, lead-based paint is the most widespread and dangerous high-dose source of lead exposure for young children. There are approximately half a million U.S. children ages one to five years with BLLs above five micrograms per deciliter (µg/dL), a level at which CDC recommends public health actions be initiated. No safe BLL in children has been identified, and exposure can affect nearly every system in the body. Because lead exposure often occurs with no obvious symptoms, it frequently goes unrecognized. Children at higher risk for lead exposure are poor, are members of racial-ethnic minority groups, are recent immigrants, live in older, poorly maintained rental properties, or have parents who are exposed to lead at work.
   
2. Percentage of Medi-Cal children up to age three receiving BLL screening. DHCS and DPH provided the ESTM Committee with an updated percentage of the number of children in Medi-Cal who have received a BLL screening test for an oversight hearing by that committee conducted in February 2018. BLL data collected by DHCS and DPH is very different. Medi-Cal data is based on the submittal of a claim or encounter that includes specific procedure and diagnosis codes that indicate a BLL screening has been performed. DHCS receives administrative data in the forms of claims (for fee-for-service beneficiaries) or encounter data (for Medi-Cal managed care enrollees). Such data only indicates a BLL test occurred if Medi-Cal was billed specifically for a BLL test. DHCS’ data would not indicate the completion of a BLL test if a primary care provider performed the test but only billed for an office visit. In contrast, DPH receives data on BLL tests performed at laboratories, including those in a physician’s office. DPH has limited data on who is and who is not a Medi-Cal beneficiary. When the data from DPH is added to the data from DHCS, the percentage of children 12 to 23 months old who were continuously enrolled in Medi-Cal for a year for a year and who were screened for lead was 48.8%. Among those 24 to 35 months old, the percentage of children screened was 40.5%.
3. Related legislation. SB 1097 (Leyva) requires DPH’s report regarding the effectiveness of appropriate lead poisoning case management efforts to include additional data, including the number of children identified as being at risk who received blood testing. Requires the report to indicate whether the sources of lead poisoning described under this bill have been removed or abated. Requires DPH to post the report its Web site. Requires DPH to incorporate the data collected and the report into the Healthy Communities Data and Indicators Project, as specified. SB 1041 is set for hearing on June 26, 2018 in the Assembly Health Committee.

AB 11 (McCarty) requires that screening services available under the Early and Periodic Screening, Diagnostic and Treatment Program specifically include screening services for individuals zero to three years of age, inclusive, in compliance with the periodicity schedule and the standardized and validated screening tool that are established by the Bright Futures/American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care and by any future updates to those recommendations. AB 11 is set for hearing on June 27, 2018 in the Senate Health Committee.

AB 2122 (Reyes) establishes requirements for DHCS and Medi-Cal managed care plans to ensure children receive blood lead screening, information about lead exposure and testing and follow-up services for children with an elevated blood lead level, including a contractual requirement for plans and its contractors to meet the lead testing standard of care under federal Medicaid law. Establishes state goals for children at risk of lead exposure and for blood testing for children under age who are eligible for Medi-Cal. Requires DHCS to include blood lead screening tests as a performance measure in its annual External Accountability Set, and requires DHCS to annually create a report detailing the DHCS’ progress toward the state goals. Requires DPH to prepare provider training guidelines, curriculum, and resources that are required to be used to educate providers about childhood lead poisoning prevention, childhood lead exposure risks, childhood lead exposure health effects, and sources of childhood lead exposure at the state, regional, and local levels. AB 2122 is set for hearing on June 27, 2018 in the Senate Health Committee.

1. Prior legislation. AB 1316 (Quirk, Chapter 507, Statutes of 2017) requires DPH to revise its regulations for the Childhood Lead Poisoning Prevention Program (CLPP) to redefine the assessment of risks for the purposes of evaluating a child's risk for lead exposure. Requires DPH to consider the most significant risk factors for childhood lead exposure, as specified. Makes several technical and clarifying changes to the CLPP statute and the mandate on health care service plans that offer preventive services for children.
   

AB 247 (Garcia of 2017) would have established a Statewide Lead Advisory Taskforce to review and provide recommendations regarding policies and procedures to reduce lead poisoning in the state. AB 247 was vetoed by the Governor who indicated: “The responsibilities of this task force would be duplicative of ongoing work by the Office of Environmental Health Hazard Assessment, DPH, the State Water Resources Control Board, and the Department of Toxic Substances Control. Coordination and evaluation of procedures to reduce childhood lead poisoning is being accomplished administratively amongst these agencies so there is no reason to divert resources to a task force.”

SB 775 (Ridley-Thomas of 2007) would have, among other provisions, required DPH to make available on its Web site the most current information on lead, as specified, and would have required providers primarily responsible for providing prenatal care to explain to pregnant women that lead poisoning prevention information is available on the Web site or provide other information about lead poisoning prevention. SB 775 was vetoed by the Governor who indicated: “While I support programs to reduce lead exposure for children, this bill is duplicative of existing state requirements and may jeopardize overall funding for lead poisoning prevention. Many of the bill's provisions are unnecessary and are already being accomplished administratively.”

1. Support. The Association of California Healthcare Districts (ACHD) writes in support that recent data from DPH shows that an estimated 88% of lead poisoned children in California are on Medi-Cal, that all children on Medi-Cal are required to be tested for lead exposure/poisoning twice by age three, yet only 28% of these kids are being tested. ACHD writes that this bill would require the two state agencies to better coordinate to use their data to ensure children who are risk of lead poisoning are indeed being tested.
   
   The Environmental Working Group (EWG) writes in support, that since the 1970s, federal and state policies banning the use of lead in gasoline and paint have resulted in drastic reductions in childhood lead exposure. However, legacy lead – lead remaining in paint, plumbing, contaminated soil, and pipes – continues to endanger children who encounter this known neurotoxin in their homes and other environments, such as day care facilities. As housing and other types of building infrastructure age, childhood lead exposure risks may increase. Paint peels, lead leeches into soil, and leaded pipes decay and contaminate otherwise potable water sources. In addition, new sources of lead have been identified, and local officials report that children are frequently exposed to potentially dangerous levels of lead by consuming certain imported spices, playing with imported toys, or using foreign manufactured cosmetics or ritual items. Some children and families are also inadvertently exposed to lead through use of non-prescription home remedies. While many of California’s youngest children are still exposed to lead, many who are at the highest risks of lead poisoning are not tested for lead exposure as required by law. A recent analysis state data found that, between 2012 and 2016, three-quarters or nearly 529,000 on average of the state’s 12 and 24-month old children who are most at risk of lead-poisoning, did not receive blood lead screenings in accordance with federal and state regulations. This finding supports another analysis, published last year in the peer-reviewed journal Pediatrics. This analysis found that more than 63% of California’s children with elevated blood lead levels above 10 µg/dL are not identified. EWG concludes that California’s kids deserve better.
   
2. DHCS proposed amendments. The author received amendments from DHCS, which would amend the requirement that laboratory report blood lead tests to DPH. Under that law, information that is held by DPH that is reported from a laboratory is required to confidential, except that DPH may share the information for the purpose of surveillance, case management, investigation, environmental assessment, environmental remediation, or abatement with the local health department, authorized environmental health agency authorized, or building department. DHCS’ proposed amendment would allow DPH to also share this information with DHCS for official governmental program purposes.

SUPPORT AND OPPOSITION:

Support: Association of California Healthcare Districts

Environmental Working Group
Western Center on Law and Poverty

Oppose: None received

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ASSEMBLY THIRD READING

ATR Bill Id:AB 2976

Author:(Quirk)

As Amended Ver:March 15, 2018

Majority vote

SUMMARY: Requires the Department of Public Health (DPH) to coordinate with state entities, including the Department of Health Care Services (DHCS), that are responsible for administering publicly funded programs for low-income children to gather data to determine whether children are being screened for lead poisoning pursuant to current regulations.

FISCAL EFFECT: According to the Assembly Appropriations Committee, costs to DPH and DHCS, likely in the range of $150,000 for each department (General Fund (GF) for DPH; GF/federal for DHCS), to continue current work on comparing Medi-Cal encounter data with DPH case management system data. Depending on challenges with data-matching and if information technology solutions were needed, these costs could be lower or higher.

COMMENTS: According to the author, the Environmental Safety & Toxic Materials Committee (ESTM Committee) held an oversight hearing on February 13, 2018, to better understand the compliance rate for testing children on state assistance programs for lead exposure. As chair of the ESTM Committee, the author sought to better understand how our state health departments track children on low income state assistance programs, such as Medi-Cal, to ensure they are receiving the blood lead tests as they should. State regulation for the Childhood Lead Poisoning Prevention Program, as well as federal law for Medicaid, requires all children on Medi-Cal to have their blood lead tested at specified ages. At the hearing, we learned that data from DHCS show that only about 37% of children ages one-year old and two-years old who are continuously enrolled in Medi-Cal, on average, have been blood tested annually for the past five years. Part of the problem lies with the fact DPH does not obtain any information about whether a child is on a state assistance program or not, making it difficult for DPH to know its compliance status or do anything about it if compliance is low. This bill will codify DPH's regulatory requirement for childhood lead testing and require DPH to coordinate with the state entities, including but not limited to DHCS, that are responsible for administering the publicly funded programs for low-income children so that DPH can gather the appropriate data to determine whether children are being screened for lead poisoning as required.

All children who are receiving services through publicly funded programs for low-income children, as well as children living or spending a lot of time in a place built before 1978 with deteriorated paint or recent renovation, are deemed to be at high risk of lead poisoning and, under California regulations, must be blood lead tested at one and two years of age. Refugees and other children who have lived in or spent time in another country may also be at increased risk. Although all children are at risk for lead exposure, poor and minority children are disproportionately affected. The only way to know if a child is lead poisoned is to order a blood lead level test (BLL). Young children from six months to six years (particularly those at one and two years) are at greatest risk. Under California regulations, providers must give anticipatory guidance on lead poisoning prevention at each periodic health assessment from the age of six months up to 72 months. The provider must order BLLs at the ages of one and two years and whenever a child under six years is identified as having missed the required tests, a change in circumstances has put the child at risk, or if requested by the parent or guardian. Refugees must be screened upon arrival and at specified times thereafter.

The Early Periodic Screening Diagnostic and Treatment (EPSDT) guidelines and the American Academy of Pediatrics’ Bright Futures (Bright Futures) guidelines both have recommendations regarding blood level testing and risk assessments. EPSDT requires a blood lead test for children enrolled in Medicaid at 12 months and 24 months. If any child enrolled in Medicaid between 24 and 72 months does not have a record of a previous blood lead test, they must receive one. The Bright Futures recommends a risk assessment for lead exposure and subsequent blood lead test if the risk assessment is positive. The Bright Futures periodicity schedule recommends a risk assessment at well-child visits for the following ages: six, nine, 12, 18, and 24 months and at three, four, five, and six years of age.

The Association of California Healthcare Districts (ACHD) states in support that lead exposure is an important public health and health equity issue. While children are exposed to lead in a myriad of ways, poor and minority children are disproportionately affected. Calcium and iron prevent lead uptake in the body; however, poor nutrition can lead to higher risk for lead absorption. Children who lack access to nutritious foods are considered to be a higher risk for lead exposure. Low-income children run a higher risk of lead exposure from old paint due to a tendency to reside in older, less maintained housing. Lead is a potent neurotoxin and elevated blood lead levels are associated with increased risk of lower intelligence quotient scores, academic failure, and aggressive behavior in children. ACHD notes that recent data from DPH shows an estimated 88% of lead poisoned children in California are on Medi-Cal All children enrolled in Medi-Cal are required to be tested for lead exposure/poisoning twice by age three, yet only 28% of these kids are being tested. ACHD concludes that this bill would require the two state agencies to better coordinate to use their data to ensure children who are at risk of lead poisoning are indeed being tested.

Analysis Prepared by: Paula Villescaz / HEALTH / (916) 319-2097 FN: 0003332

Date of Hearing: May 16, 2018

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez Fletcher, Chair

ABPCA Bill Id:AB 2976

Author:(Quirk) – As Amended Ver:March 15, 2018

Urgency: No State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill requires the California Department of Public Health (CDPH) to coordinate with the Department of Health Care Services (DHCS) to gather data to determine whether low-income children are being screened for lead poisoning pursuant to current regulations.

FISCAL EFFECT:

Costs to CDPH and DHCS, likely in the range of $150,000 for each department (GF for CDPH; GF/federal for DHCS), to continue current work on comparing Medi-Cal encounter data with CDPH case management system data. Depending on challenges with data-matching and if information technology solutions were needed, these costs could be lower or higher.

COMMENTS:

1. Purpose. According to the author, the Environmental Safety & Toxic Materials (ESTM) Committee held an oversight hearing on February 13, 2018, to better understand the compliance rate for testing children on state assistance programs for lead exposure. The author of this bill, as committee chair, sought to better understand how state health departments track children on Medi-Cal to ensure they are receiving the blood lead tests as they should. This bill intends to codify the collaborative efforts the two departments have initiated as a result of this oversight.
2. Background. Lead is harmful to neural development of children and no level of lead in the blood is safe. Because there is no safe level of lead, two main public health strategies are employed: educating parents and caregivers about identifying and keeping children safe from lead hazards, and preventing lead poisoning through environmental remediation. Blood lead tests are also recommended for children who are at-risk and at certain ages, and current law and regulation requires providers to administer such tests. If a blood test shows a high blood lead level, a child is contacted by a state-contracted, locally administered case management program that includes public health nursing and environmental follow-up to detect and eliminate lead exposure pathways.

DHCS does not make compliance with blood lead screening tests a performance metric for its contracting managed care health plans. However, contracts do require the plans make reasonable attempts to ensure the blood lead screen test is provided and requires providers to document attempts to provided tests. There are other requirements on health care providers in law and regulation to provide screening tests to a targeted population at appropriate intervals. All children enrolled in publicly funded health care programs (e.g., Medi-Cal) are considered part of the target population for screening, which also includes children living in older homes.

There appears to be confusion over the current level of provider compliance with the blood lead screening mandate and whether children are getting the tests that are recommended or required. At the February ESTM committee oversight hearing examining the issue, DHCS indicated data showed only 37% of enrolled one- and two-year-old children received tests. At the same time, laboratory data from CDPH appear to indicate a higher level of screening of low-income children.

CDPH maintains a web-based system whereby blood lead test results are reported electronically to the department. The lead test results are aggregated so that repeat blood lead tests for the same individual can be identified and are stored together. This system has been mostly used to identify cases of high blood levels for individual case management, but CDPH and DHCS have recently begun collaborating, pursuant to a request from the ESTM committee, to match Medi-Cal data with data in CDPH's system.

1. Related Legislation. AB 2122 (Reyes), also being heard today by this committee, requires DHCS to undertake a number of activities to ensure children receive blood lead tests.

Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081

Date of Hearing: April 17, 2018

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 2976

Author:(Quirk) – As Amended Ver:March 15, 2018

SUBJECT: Childhood lead poisoning: prevention.

SUMMARY: Requires the Department of Public Health (DPH) to coordinate with state entities, including the Department of Health Care Services (DHCS), that are responsible for administering publicly funded programs for low-income children to gather data to determine whether children are being screened for lead poisoning pursuant to current regulations.

EXISTING LAW:

1. Requires DPH, under the Childhood Lead Poisoning Act of 1991, to establish a childhood lead poisoning prevention program to increase awareness regarding the hazards of lead exposure, reduce lead exposure, increase the number of children assessed and their blood tested for lead poisoning, and identify and conduct medical follow-up of high-risk children.
   
2. Establishes the Childhood Lead Prevention Fund to support lead poisoning prevention programs for children.
3. Requires DPH to revise its regulations for the Childhood Lead Poisoning Prevention Program (CLPPP) to redefine the assessment of risks for the purposes of evaluating a child's risk for lead exposure.
4. Requires DPH to consider the most significant risk factors for childhood lead exposure, including, but not limited to, a child's time spent in a home, school, or building built before 1978, a child's proximity to a former lead or steel smelter or an industrial facility that historically emitted or currently emits lead, a child's proximity to a freeway or heavily travelled roadway, potential risk factors for lead exposure, and known sources of lead contamination.
5. Requires DPH to prepare and prominently post on its Internet Website information about DPH's progress in meeting the CLPPP goals specified in statute, including an annually updated analysis of the data and information identified and compiled related to prevalence, causes, occurrences, and significant target areas related to lead exposure rates.

FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, the Environmental Safety & Toxic Materials Committee (ESTM Committee) held an oversight hearing on February 13, 2018, to better understand the compliance rate for testing children on state assistance programs for lead exposure. As chair of the ESTM Committee, the author sought to better understand how our state health departments track children on low income state assistance programs, such as Medi-Cal, to ensure they are receiving the blood lead tests as they should. State regulation for the CLPPP, as well as federal law for Medicaid, requires all children on Medi-Cal to have their blood lead tested at specified ages. At the hearing, we learned that data from DHCS show that only about 37% of children ages one-year old and two-years old who are continuously enrolled in Medi-Cal, on average, have been blood tested annually for the past five years. Part of the problem lies with the fact DPH does not obtain any information about whether a child is on a state assistance program or not, making it difficult for DPH to know its compliance status or do anything about it if compliance is low. This bill will codify DPH's regulatory requirement for childhood lead testing and require DPH to coordinate with the state entities, including but not limited to DHCS, that are responsible for administering the publicly funded programs for low-income children so that DPH can gather the appropriate data to determine whether children are being screened for lead poisoning as required.
2. BACKGROUND. All children who are receiving services through publicly funded programs for low-income children, as well as children living or spending a lot of time in a place built before 1978 with deteriorated paint or recent renovation, are deemed to be at high risk of lead poisoning and, under California regulations, must be blood lead tested at one and two years of age. Refugees and other children who have lived in or spent time in another country may also be at increased risk. Although all children are at risk for lead exposure, poor and minority children are disproportionately affected. The only way to know if a child is lead poisoned is to order a blood lead level test (BLL). Young children from six months to six years (particularly those at one and two years) are at greatest risk. Under California regulations, providers must give anticipatory guidance on lead poisoning prevention at each periodic health assessment from the age of six months up to 72 months. The provider must order BLLs at the ages of one and two years and whenever a child under six years is identified as having missed the required tests, a change in circumstances has put the child at risk, or if requested by the parent or guardian. Refugees must be screened upon arrival and at specified times thereafter.
   
   1. Sources of Lead. According to DPH, the common sources of lead include:
      
      1. Lead-based paint (pre-1978) in homes and on furniture, including paint chips;
      2. Lead contaminated soil;
      3. Dust contaminated with lead from paint or soil;
      4. Imported cosmetics;
      5. Imported pottery and dishware with leaded glaze;
      6. Some imported foods; and,
      7. Metal jewelry.
   2. Childhood lead poisoning prevention branch (CLPPB). Once a child has become exposed to lead, it is crucial to identify and remove the sources of exposure. CLPPB, a branch of DPH, and its local programs can help identify lead sources and collaborate in a treatment response, as well as provide educational materials and technical knowledge. There is a CLPPP in most counties and some cities. The local programs (or the CLPPB in counties without a local CLPPP) offer a range of supportive interventions for the family of a child or young adult up to the age of 21 years. For children with BLLs meeting eligibility criteria, these also include home visits by a Public Health Nurse (PHN) and investigations by an environmental professional. There is no charge to the family for these services; eligibility is based on BLLs, not income or insurance status.
   3. Periodicity Schedules. The Early Periodic Screening Diagnostic and Treatment (EPSDT) guidelines and the American Academy of Pediatrics’ Bright Futures (Bright Futures) guidelines both have recommendations regarding blood level testing and risk assessments. EPSDT requires a blood lead test for children enrolled in Medicaid at 12 months and 24 months. If any child enrolled in Medicaid between 24 and 72 months does not have a record of a previous blood lead test, they must receive one. The Bright Futures recommends a risk assessment for lead exposure and subsequent blood lead test if the risk assessment is positive. The Bright Futures periodicity schedule recommends a risk assessment at well-child visits for the following ages: six, nine, 12, 18, and 24 months and at three, four, five, and six years of age.
3. SUPPORT. The Association of California Healthcare Districts (ACHD) states in support that lead exposure is an important public health and health equity issue. While children are exposed to lead in a myriad of ways, poor and minority children are disproportionately affected. Calcium and iron prevent lead uptake in the body; however, poor nutrition can lead to higher risk for lead absorption. Children who lack access to nutritious foods are considered to be a higher risk for lead exposure. Low-income children run a higher risk of lead exposure from old paint due to a tendency to reside in older, less maintained housing. Lead is a potent neurotoxin and elevated blood lead levels are associated with increased risk of lower intelligence quotient scores, academic failure, and aggressive behavior in children. ACHD notes that recent data from DPH shows an estimated 88% of lead poisoned children in California are on Medi-Cal All children enrolled in Medi-Cal are required to be tested for lead exposure/poisoning twice by age three, yet only 28% of these kids are being tested. ACHD concludes that this bill would require the two state agencies to better coordinate to use their data to ensure children who are at risk of lead poisoning are indeed being tested.
4. RELATED LEGISLATION.
   1. AB 2122 (Reyes) mandates in state law that all kids in Medi-Cal receive a blood lead screening at 12 and 24 months of age. AB 2122 is pending in the Assembly Health Committee.
   2. SB 1041 (Leyva) requires DPH to annually notify providers and providers to notify parents of lead testing requirements. SB 1041 is pending in the Senate Appropriations Committee.
   3. AB 1316 (Quirk), Chapter 507, Statutes of 2017, requires DPH to revise its regulations for the CLPPP to redefine the risk assessment for the purposes of evaluating a child’s risk for lead exposure. Specifically, requires DPH to consider the most significant risk factors, including, but not limited to, a child’s time spent in a home, school, or building built before 1978, a child’s proximity to a former lead or steel smelter, a child’s proximity to a freeway, a child’s consumption of imported foods and spices, and other known risk factors for lead exposure.
5. PREVIOUS LEGISLATION. SB 775 (Ridley-Thomas) of 2007 would have, among other provisions, required DPH to make available on its Website the most current information on lead, as specified, and would have required providers primarily responsible for providing prenatal care to explain to pregnant women that lead poisoning prevention information is available on the Website or provide other information about lead poisoning prevention. SB 775 was vetoed by the Governor who indicated: “While I support programs to reduce lead exposure for children, this bill is duplicative of existing state requirements and may jeopardize overall funding for lead poisoning prevention. Many of the bill's provisions are unnecessary and are already being accomplished administratively.”

REGISTERED SUPPORT / OPPOSITION:

Support

Association of California Healthcare Districts

Environmental Working Group

Opposition

None on file.

Analysis Prepared by: Paula Villescaz / HEALTH / (916) 319-2097