Residential Lead Abatement
Chapter VI

Chapter Six
Other States 

As part of this study, the program review committee examined lead programs in other state to compare their laws, regulations, and policies with those in Connecticut.  Most states have certain key components that are an integral part of their lead programs.  Those key components generally deal with the following areas: condition of housing stock; lead screening and reporting results; types of interventions; abatement requirements and enforcement orders; and financial resources.  These basic program elements can be found in some form in every state’s lead program.

Information was gathered via phone surveys and reviews of applicable statutes and regulations.  All New England states were selected to be part of the analysis, as well as Maryland because it operates an innovative program considered a model at the national level. 

Comparative Findings

Beyond the key components, several general themes among state lead prevention programs emerged:

·       governmental activities related to lead prevention and abatement funding are fragmented and multi-layered – usually housing and public health agencies are involved at the state level, as well as counties and municipalities at the regional and local levels;

·       data collection on the number of children screened, public health orders issued, and the amount of federal or state financial assistance available to property owners for abatement is problematic, and the program fragmentation noted above makes program effectiveness difficult to evaluate;

·       staffing and financial resources vary among states, resulting in public health orders to manage and abate lead hazards not uniformly enforced, and oversight and follow-up to ensure compliance not always performed; and

·       interpretation of state lead statutes and/or regulations at the local level are often conflicting because of the decentralized nature of the program.

In addition, all states acknowledged the financial ability of property owners to comply with the law has been spotty.  Therefore, orders may linger, or properties may be abandoned.  As a result, many states have recently begun to revise their programs by creating financial incentives for property owners and focusing on increasing primary prevention activities, as has been recommended in this report, to reduce children’s exposure to lead hazards.  This generally requires focusing on identifying and correcting only lead hazards (not all lead-based paint) and promoting the concept of a lead-safe environment.  This chapter provides a comparative analysis of the states selected for review.

Housing stock.  In order to understand the extent of the problems in abating lead from housing and the associated costs, Table VI-1 shows the number of housing units built prior to 1950 in each state -- the category of housing considered most dangerous.  Connecticut’s pre-1950 housing units number nearly 500,000 or almost 35 percent of the housing stock.  The portion of the United State’s housing stock built before 1950 is 27 percent.

Housing stock targeted.  Most state’s lead laws target housing built before 1978. the year lead-based paint was banned from use in the United States.  Table VI-2 identifies the property year targeted by each state’s law.  As the table shows, all New England states target housing built prior to 1978.  Maryland law focuses only on pre-1950 properties, when it is assumed almost all paint contained high contents of lead.

Lead screening.  Screening children under six years of age is considered critical in detecting a child’s exposure to lead, since most of the signs of lead poisoning are not obvious. Screening is conducted by using a capillary (fingerstick) or venous blood test.  The committee examined state screening policies to determine if any states statutorily mandate the screening of children for lead poisoning.  Table VI-3 shows each state’s screening policy.

In addition, it is important to note Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program mandates all Medicaid children be screened at ages one and two regardless of state policy.  Four states maintain a policy similar to Medicaid by mandating lead screening at particular ages.  Rhode Island and Massachusetts have the most comprehensive policies, screening children through ages six and four respectively.  Maryland’s policy differs slightly in that it pertains only to those children entering child-care facilities and does not include children who would be cared for at home.

Reportable blood lead levels.  Some states mandate lead screening test results be reported to the state public health department, while others only require reporting if lead in the blood exceeds a specific level.  Requiring all test results be reported provides a state with better planning information regarding the extent and geographic location of lead screening, as well as the incidence and prevalence rates of elevated blood lead levels within the population targeted.  Table VI-4 shows reportable BLLs for each state examined.

All but two of the states examined by the program review committee mandate reporting of lead screening tests.  Maine only requires reporting if blood lead levels are at or above 20mcg/dL and Vermont for levels at or above 10 mcg/dL.  Connecticut passed legislation that requires all results be tracked as of October 1, 1998; previously only levels at or above 10 mcg/dL were reportable.

Intervention.  The Centers for Disease Control recommend various actions be taken at specific blood lead levels.  These actions include: 1) education and nutrition counseling; 2) case management; 3) environment inspections of a child’s residence; and 4) medical evaluations.   Table VI-5 compares the blood lead level at which each state requires a response, including the minimum blood lead level that triggers an environmental inspection (i.e., the dwelling of a child is inspected to determine if lead-based paint hazards are present).

            Education and nutritional counseling.  The provision of education and nutrition information on ways to reduce children’s exposure to lead hazards is an important step in preventing children’s blood lead levels from rising.  If action can be taken early, less expensive methods can be used to reduce exposure.  Almost all states surveyed, except Maine and New Hampshire, require education and nutrition information be provided to the parents or guardians of children with BLLs equal to or greater than 10 mcg/dL.

            Case management.  Case management is defined to mean coordination, provision, and oversight of the services to the family that are necessary to ensure lead-poisoned children achieve a reduction in blood lead levels.  Four of the seven states surveyed require case management services to be provided to children with BLLs equal to or greater than 15 mcg/dL.  Connecticut, Maine, and New Hampshire do not require case management until a child’s BLL reaches 20 mcg/dL or more. 

Environmental inspections.  The CDC recommends an environmental inspection of a child’s residence if a child has a BLL equal to or greater than 20 mcg/dL or two tests within 3 consecutive months equal to or greater than 15 mcg/dL.  The environmental inspection is “triggered” by a BLL at or above 20 mcg/dL in five of the states surveyed, except for Massachusetts and Maryland.  In Massachusetts, an environmental inspection is conducted if a child’s BLL is equal to or greater than 20 mcg/dL, however, the property owner can refuse admittance.  A BLL at or above 25 mcg/dl results in the ability of the State Department of Health to obtain a warrant to inspect the child’s dwelling.  In Maryland, inspections are conducted if a child has a BLL equal to or greater than 20 mcg/dL or after two consecutive BLL’s at or above 15 mcg/dL.

Management and abatement of lead.  Table VI-6 outlines each state’s policy on whether interim controls are allowed in dwellings where a lead poisoned child resides and identifies the types of surfaces requiring abatement.  Interim controls are generally defined as temporary measures used to control urgent lead hazards immediately and reduce exposures.  For example, an interim control would be to install metal inserts in window wells, rather than replacing the entire window.  Connecticut and Maine do not allow interim controls in instances where an abatement order is issued (although Connecticut’s proposed regulations would allow their use). 

The committee examined the lead policy of each state in terms of whether the law requires a property to be fully abated or allows abatement of lead hazards only.  Most states surveyed allow property owners to abate only lead hazards. Massachusetts is the only state examined by the committee that requires property owners to eliminate all lead-based paint found on the property, whether or not such paint is directly hazardous to the occupants. As shown in the table, all states, except Massachusetts, require loose and friction surfaces to be abated.  Vermont’s lead law is preventative and mandates essential maintenance practices be conducted on all rental properties and child care facilities to prevent lead exposure.  The methods include visual inspections, installing window well inserts, specialized cleaning, and stabilizing paint—in many ways, similar to ongoing interim controls. 

Enforcement of orders.  A variety of methods are used to enforce compliance with lead orders issued to property owners.  Rhode Island and Maine use their states attorneys general to bring contempt orders against noncompliant owners.  Connecticut and Massachusetts rely upon both state and local court processes in enforcing compliance.  Maryland, meanwhile, leaves the enforcement to the local health boards.  Vermont’s law is strictly voluntary.  It seeks a collegial, collaborative approach, and although the Vermont Department of Health has the statutory authority to issue health orders for correction of lead hazards, none have ever been issued.

Programs and financial resources.  Almost all states have programs that financially assist property owners to manage and/or abate lead from their properties.  Three states offer tax credits of some sort to property owners:

·       Massachusetts provides a tax credit of $1,500 for full abatement and $500 if interim controls are implemented;

·       Rhode Island offers tax credits of up to $1,000 per unit to property owners who abate lead; and

·       Maine provides tax credits, but they are limited to owners of child-care facilities under lead abatement orders. 

Table VI-7 shows the type of financial assistance available by state, and Table VI-8 outlines the average loan amount issued by selected states (those that had information).  Statewide loan and grant assistance is available from every state.

Medicaid Reimbursement

The program review committee also examined national survey data to determine the number of states that receive Medicaid reimbursement for specific responses provided to a child with an elevated blood lead level. Supplemental information regarding Medicaid reimbursement was obtained from a survey conducted by the Alliance to End Childhood Lead Poisoning and the National Center for Lead-Safe Housing.  In addition, representatives from Rhode Island, as well as the regional Health Care Financing Administration, visited Connecticut to discuss their recently approved Medicaid waiver that allows window replacement in dwellings occupied by a child who is lead poisoned.

Studies have shown children who are Medicaid recipients are at a high risk for elevated blood lead levels.  Medicaid’s EPSDT program requires all Medicaid children be screened at ages one and two for lead poisoning, regardless of a state’s lead screening policy.  In addition, children over the age of 24 months, up to 72 months, who have not been screened previously should also be screened.  Several states have established a mechanism for the Medicaid program to reimburse for case management services and environmental investigations if a child has an elevated blood lead level.  By classifying these services as a Medicaid benefit, states have been able to receive matching assistance from the federal government.

Case management.  As noted above, case management is defined as the coordination, provision, and oversight of services to a family that are necessary to ensure lead-poisoned children achieve a reduction in blood lead levels. According to the survey conducted by the Alliance to End Childhood Lead Poisoning, 20 of the 51 state programs (and the District of Columbia) responding have a process in place for Medicaid reimbursement for case management.  Five of the 20 states that responded positively, however, indicated they had not yet received any Medicaid reimbursement.  Table VI-9 identifies the states that receive case management reimbursement.  Reimbursement ranged from $25 per visit in Wisconsin to $70 per visit in Michigan.

Environmental investigations.  The majority of states (35 of the 49 respondents to the survey question) use 20 mcg/dL as the blood lead level that triggers an environmental investigation.  Of these, 13 also provide the service for a persistent or repeated level at 15 mcg/dL.  A smaller number of states conduct environmental investigations at lower levels – nine states at 15 mcg/dL, and two between 10 and 15 mcg/dL.

Several states indicated on the alliance’s survey that they receive Medicaid reimbursement for the environmental investigation.  Of the 51 programs that replied, 22 states have established a mechanism for the Medicaid program to reimburse for environmental investigations to determine the source of lead exposure for a lead-poisoned child.  Table VI-10 outlines which states receive Medicaid funding for environmental inspections.  As shown, Connecticut (as well as Maine, Massachusetts, and New Hampshire) does not receive Medicaid funding for inspection-related costs.

            Table VI-11 shows the amount reimbursed by Medicaid for an environmental inspection.  The reimbursement amount ranges from less than $50 to over $300.  The amount of Medicaid reimbursement for the majority of states is between $100 and $199.

            It is important to note the Health Care Financing Administration (HCFA), in a letter to all state Medicaid directors dated October 22, 1999, clarifies under what circumstances an environmental investigation may be covered under Medicaid.  First, a child must have an elevated blood lead level.  In addition, the scope of the investigation is limited.  HCFA only reimburses for a health professional’s time and activities during an on-site investigation of a child’s primary residence.  Medicaid funds are not available for the testing of environmental substances such as water, paint, or soil. 

Waiver for window replacement.  Finally, Rhode Island received approval for a Medicaid waiver that would provide Medicaid coverage for window replacement in a unit where a child was a Medicaid recipient and had a blood lead level equal to or greater than 20 mcg/dL. Windows are not a medical service traditionally covered by Medicaid.  The waiver was approved by the federal Health Care Financing Administration in December 1998.  During its first year, Rhode Island anticipates spending an average of $1,830 per unit and providing window replacements in 200 to 300 units.  Total spending is estimated at $366,000 to $549,000.

            Landlords and homeowners would not initially be required to contribute financially for the new windows.  However, after the state arranges to have the windows replaced, a lien would be placed on the property for the same amount as the cost of the work.  The property owner would pay off the lien over time or wait until the property is sold.

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