Back in the late 1960s, Boston was the center of research activity in the study of the health consequences of lead poisoning in children, and the research helped spawn an aggressive advocacy effort. Paul Hunter, acting director of the Massachusetts Childhood Lead Poisoning Prevention Program, says lobbying by the advocacy group led to the first lead law in the nation, enacted in 1971, requiring lead abatement -- to a level of 4 feet -- in any home where a child under the age of 6 years lived.
Since then, the state has repeatedly strengthened its laws, and the number of children found to have blood-lead levels greater than 10 micrograms per deciliter, the current acceptable limit, has declined by more than half since 1994 -- from 31,872 to 13,566 in 1998 -- even though Massachusetts ranks second in the nation for old housing.
Owners who have their homes de-leaded qualify for a $1,500 state income-tax credit per residential unit. Homeowners or landlords must hire a licensed de-leader, or, if an owner or the owner's agent wants to perform certain low-risk de-leading, he or she must review training materials and take an exam. Lead inspections and notices of abatement compliance must be submitted to the state, allowing the development of a database of lead-safe housing that now contains 120,000 units. The abatement process isn't cheap: The average cost of de-leading for the most recent 100 properties was $4,800, though housing values there are relatively high, with an average sale price of about $180,000, Hunter says.
The state also aggressively screens children -- Massachusetts state law mandates that every child between the ages of 9 months and 4 years be screened annually for the presence of lead. The compliance rates are relatively high, ranging from 65-70 percent for children on Medicaid and 72 percent for all others.
Massachusetts' budget for the lead-poisoning-prevention program is about $4.5 million annually, with another $4.5 million for a loan/grant program to help pay for de-leading, in addition to city and federal funding.
Missouri is another story.
The state had no childhood-lead-poisoning program whatsoever until 1993, and today that program's total funding is about $700,000, largely from a grant from the Centers for Disease Control and Prevention and about $100,000 from state funds. Most of the money goes to local health departments, including $160,000 for St. Louis.
Missouri has no law requiring screening but recommends that all children be screened for lead at least twice before the age of 2. Only 11 percent of Missouri children under the age of 6 are actually screened each year. Federal regulations require that all Medicaid recipients be screened at 12 and 24 months, but those numbers are dismal, too. In November, Missouri Attorney General Jay Nixon sued two of the HMOs that serve children on Medicaid as part of the MC Plus program in the St. Louis area -- Healthcare USA of Missouri and Prudential Health Care Plan Inc. -- claiming that breach of contract and Medicaid fraud were committed when the HMOs accepted payments for lead testing that was not performed. An external review by the Missouri Patient Care Review Foundation found that Prudential tested only 14 percent of children at 12 months and none at 24 months; Healthcare USA tested 29 percent of the children at 12 months, the review found, and just 17 percent at 24 months.
The same review involved about a dozen Medicaid providers statewide, and none came even close to 100 percent compliance. Care Partners, for instance, which includes Washington University Primary Care Network, tested just 36 percent at 12 months and 29 percent at 24 months, and the Mercy Health Plan screened just 18 percent at 12 months and 9 percent at 24 months. Nixon explains his decision to sue by saying: "We were paying for 100 percent of the kids to be tested and remediated," he says. "Far fewer than a quarter of them were even being tested. We want the testing done that is being paid for, and we want to get back whatever money was collected by them by not providing services that were paid for so we can beef up testing and remediation."
Nixon says he selectively sued only two providers because he decided to target only the two for-profit companies operating in St. Louis -- "those who are taking their profits from Missouri and giving them back to their shareholders.... That's not to say there aren't others."
Missouri lacks any legislation requiring lead hazards in residential housing to be fixed. The Governor's Lead Advisory Committee, formed last summer, has been meeting to consider what types of recommendations it wants to make, such as investment tax credits and landlord incentives, education outreach to physicians and the training of lead inspectors and contractors. But the committee is not considering a law like Massachusetts', which would require property owners to perform lead abatement on properties where children under 6 are living.
"They've talked about it a little bit in the advisory committee but the consensus of the group has been that it would never pass," says Mindy Hand, the state's coordinator of childhood-lead-poisoning prevention. "The legislation would never make it through."