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Putative Declines in Elevated Blood Lead Levels: Real or Illusory?

A Review of NJ DHSS Childhood Lead Poisoning in New Jersey, Annual Report Fiscal Year 2001

(revised February 5, 2002)


Myles O’Malley, MA

PLEASE NOTE: If you would like a complete copy of this report in Microsoft Word format, click here to download it.

The report "Childhood Lead Poisoning in New Jersey, Annual Report Fiscal Year 2001," (the Report 2001) is the fourth to be issued as required by PL 1995, Chapter 338. The information in this and last year’s Report 2000 has improved significantly. It should nonetheless be subjected to interpretation and closer analysis than, in some instances, provided by NJDHSS. Although the Report 2001 contains much information that requires reflection and research1, this review will focus on the putative declines in elevated blood lead levels and simultaneous increase in rates of lead screening. The issue is pivotal because New Jersey has a new administration and a severe budget deficit that by statute cannot be tolerated. It is imperative that all constituencies, including the State, have a fundamentally common perception of the extent, breadth and location of this disease of childhood poverty. Policy recommendations will be made.


The Report 2001 is the latest in a series that show a steady and dramatic decrease in the number of reported elevated blood lead tests in New Jersey. The Report 2001 shows that 3.8 % of children tested had elevated blood lead levels; i.e. levels => 10mcg/dL down from 5% in last year’s report. The actual number of children with elevated blood lead levels (EBLLs) declined 18% from 6,847 to 5616. Even more startling is the fact that the number of children with EBLLS => 20mcg/dL (the level at which environmental intervention is required by law) declined 27% to 947 down from 1309 in last year’s report. The Report also for the first time supplies blood lead test results dating back to 1994 for children with blood lead levels => 20mcg/dL. In 1994, there were 4757 children tested with blood lead levels of =>20 mcg/dL. The report shows a steady annual decline to the 2001 level of 947. This represents an 80% decline in this blood lead category. How are these declines explained?

There is no doubt that the Report 2001 reflects the blood lead levels of the children tested. Do these declines reflect actual declines in the populations most at risk for elevated blood lead levels? Although the Report does not categorically state that this is the case, it and the press release upon which it is based strongly suggest that that conclusion is plausible while advancing no explanations for the declines. The press release (December 17, 2001) is self-congratulatory without qualification: " ‘I am pleased to see that New Jersey is making steady, consistent progress in identifying children with lead poisoning,’ said Acting Governor Donald T. DiFrancesco."

From the Report 2001:

Trends in testing and results

These results represent the continuation of a long-term trend of decreasing numbers of children identified with elevated blood lead. The DHSS established the reporting level for elevated blood lead at 20 mcg/dL in 1993. State FY 1994 was the first full State Fiscal Year that this reporting level was in effect. Every year since then, the number of children reported with blood lead at this level or greater has declined …. In the absence of reporting of all test results, the DHSS was not able to determine if the reduction between FY 1994 and FY 2000 was due to a real decline in elevated blood lead among children, or due to a reduction in the number of children tested for blood lead. [As a consequence of transfer from Fee for Service to Managed Care, comment added]. The fact that the number of children with elevated blood lead continued to decline from FY 2000 to FY 2001, even as the number of children tested increased, may indicate that the decrease in reported children with elevated blood lead reflects a real decline in elevated blood lead in children in New Jersey throughout this period. This finding would be consistent with reductions in children with elevated blood lead reported to CDC by other states, as well as the reduction in the average blood lead level in children in national surveys.

[Reference: US Centers for Disease Control and Prevention, ‘Blood Lead Levels in Young Children – United States and Selected States, 1996-1999," Morbidity and Mortality Weekly Report, December 22, 2000, 49 (50): 1133-7.].2

The decline in childhood lead screening referred to above harkens back to the NJ 1999 Report which described a 75% reduction of lead screenings from 37,697 in FY 1995 to 9,586 in FY 1999. In the same time period, there was a 62 % reduction in blood lead levels => 20mcg/dL.3 Ironically, this reduction occurred despite the passage of the universal lead screening law in 1996 and its implementation in 1998. The decline also corresponded precisely with the large-scale enrollment of Medicaid children into Managed Care. The inference was that HMO procedural obstacles caused the decline in screening and consequent reported decline in elevated blood lead levels. The current report holds that inference suspect because screening rates, though remaining low as a percent of all those children who should have been screened, nonetheless increased in the aggregate in FY 2000 to 137,536, the first year a DHSS requirement that laboratories report all blood lead tests, and then increased by 11,697 (8.5%) for FY 2001. More children screened, dramatic reductions in numbers of lead poisoned children. How can this not be "steady progress?"


In the first instance, a decline of 80% in children with blood lead levels => 20mcg/dL from 1994 to 2001 is, without explanation,4 preposterous, and most certainly does not comport with CDC data reported in MMWR for December 22, 2000 cited by the Report 2001 above. As the CDC report makes clear, the 80% declines in children’s blood lead levels as reported in the Third National Health and Examination Survey (NHANES III, 1991-1994) commencing in the late 1970’s, was primarily the result of de-leading gasoline, the consequences of which were complete by the early 1990’s. NJ’s putative 80% decline commenced in 1995 and had nothing to do with the de-leading of gasoline.


The Report 2001 invites comparison between NJ data and the MMWR for December 22, 2000. The MMWR paper reflects blood lead tests reported to state surveillance programs for three years 1996-1998. Among the 19 states there was considerable variation, from 2.7 to 14.9, in the percentages of children tested and found to have blood lead levels => 10mcg/dL. Within individual states there was also considerable variation from county to county. That range was from 0.5% to 27.3 % lending further credence to the proposition that childhood lead poisoning is localized and concentrated. Does New Jersey data follow the trend indicated by the MMWR paper?

The following table is reprinted from the MMWR paper:

Table 1. Percentage of children tested aged <6 years with elevated blood levels (EBLLs), by year – Selected states, 1996-1998.

% Children with elevated BLLs (mcg/dl)*

Year No. Tested =>10 +>15 =>20
1996 1,220,596 10.5% 3.9% 1.9%
1997 1,183,506 8.6% 3.2% 1.5%
1998 1,256,907 7.6% 2.7% 1.2%

* Alabama, Colorado, Connecticut, Iowa, Maine, Massachusetts, Michigan, Minnesota, Montana, New Hampshire, New York, North Carolina, Ohio, Oklahoma, Utah, Vermont, Washington, Wisconsin, and Wyoming.

For three years, from 1996 to 1998 there was a decline of 27% in elevated BLLs => 10mcg/dL in the 19 states. Using a three-year period for NJ data, Annual reports showed a rate of 15.9% for FY 1999, 5% for FY 2000 and 3.8 % for FY 2001. This represents a decline of 76% from FY 1999 to FY 2001. This is not in keeping with the MMWR decline of 26%. The 2-year decline from FY 2000 to FY 2001 is also not in line with the 19 state trends for 1997 and 1998. New Jersey’s decline is 24 % as opposed to 7% for the nineteen states.

A comparison between the 19 state decline in elevated BLLs =>20mcg/dL and NJ’s data similarly does not show comparability. From the Table above, the decline in this category over the three-year period is 37%. The NJ Report 1999 showed 3% of children tested with BLLs => 20mcg/dl, the Report 2000 showed 1%, and the Report 2001 showed 0.6%. This is a decline of 80% over the three-year period as compared to the 19 state declines of 37%. From a two-year period, FY 2000 to FY 2001, the NJ decline was 40% as compared to the 19 state declines of 20%.

Across all categories of EBLLs New Jersey’s declines for similar time frames are at least twice as large as the 19 state averages and in some instances three times as large. It is also important to note that the MMWR report does not account definitively for the declines in elevated BLLS. Consequently, the explanations hypothesized in this Review of New Jersey’s declines may also apply nationally.

What follows are hypotheses that explain the NJ blood lead level declines. They require further research. But it is hoped that the discussion will foster real debate.


CDC data has made it clear that childhood lead poisoning is very much a targeted or localized phenomenon. According to NHANES III, Phase 2 data, the geometric mean of BLLs for children 1-5 years was 2.7 mcg/dL. That same study showed that low-income children living in older housing had more than a thirty-fold greater prevalence of BLLs => 10 mcg/dL. Because EBL children are so concentrated, CDC has recently issued its recommendations for targeted screening of Medicaid populations.

Analysis of New Jersey’s decline in reported EBLLs is governed from beginning to end by the fact that childhood lead poisoning strikes targeted populations. From this standpoint, we look closely at the 1994-1995 data that showed the high numbers of children with EBLLs. Next we ask whether there have occurred any significant social changes in high-risk populations or their environments that would affect the likelihood of being screened or the levels of lead in their blood. The following graph is reprinted from the Report 2001:

In 1994 and 1995, the extraordinarily high number of children with BLLs => 20 mcg/dL was the result of highly targeted system that tested 37,697 children from July 1, 1994 through June 30, 1995. Many of these children (31, 910) were tested by Local Health Departments in their Child Health Conferences (well-child clinics), the remainder presumably in physician offices as part of fee for service health care delivery. Local Health Departments tested these children if they had Medicaid coverage or were uninsured with the family income less than 250% of the Federal Poverty Level (FPL). The poor and ethnic minorities were highly represented. We know that these high numbers of EBLLs also reflected a NJ screening rate of 39% for Medicaid recipients under Early and Periodic Screening, Diagnosis and Testing (EPSDT), a high rate relative to most other states where the average was 20%.7


According to the Report 1999, there was a decline of children screened for lead poisoning from the 37,697 in FY 95 to 9586 in FY 1999, a 75% decline. The number of children with BLLs =>20mcg/dL in FY 1995 was 4187 and in FY 1999 was 1602 for a decline of 62%. Looking at the data in this time frame from FY 1995 to FY 1999, one would have to conclude that the decline in EBLLS => 20 mcg/dL was the result of declines in the number of screenings. Since the rate of EBLLs per screening actually increased, one would also have to conclude that those children screened remained highly targeted. The Report 1999 points out that the decline in screenings exactly coincides with the migration from fee for service to Managed Care. This is correct and explains, at least in part, the decline in screenings and EBLLs detected. It overlooks the equally important issue of the rate of EBLLs per number of children screened.

In both groups selection criteria remained the same; i.e., many children were screened by Local Health Departments in their Child Health Conferences using the same selection criteria as stated above (Medicaid Recipient or uninsured with income less than 250% of FPL) and others were screened in other settings with blood lead levels analyzed by private, licensed labs. Thus the children screened, though small in number, continued to represent a targeted population. The disproportion between the 75% decline in the number of children screened in this time frame and the decline in the number of children with EBLLs, 62%, could be interpreted as an increase of 13 % in EBLLs =>20-mcg/dL s or as the result of the 1999 group for some reason being more targeted. Either way, the rate of children with EBLLs -> 20 mcg/dL actually increases. The Report 1999 accepts the reported declines of EBLLs at face value and proposes the migration to Managed Care as the cause, leaving open the question whether they represent real declines in the population of children.

The data also does not support a decline in EBLLs when one looks only at children screened by Local Health Departments for FY 1998 and FY 1999. The percent of children with EBLLs => 10mcg/dL for 1998 was 14.5% and for 1 999 was 15.89% for an increase of 9.6%. Similarly, for 1998 the percent of children with EBLLs =>20mcg/dL was 2.8 and for 1999 was 3.7 % for an annual increase of 32%.8

From FY 1994 through FY 1999, the data simply does not support even the speculation that the decline in reported EBLLS represented real declines for the population of children as a whole. Indeed, the data points in an opposite direction.

The data for Reports 2000 and 2001 present a somewhat different analytical challenge, since they reflect a change in NJDHSS policy that required, as of July 1, 1999, that all blood lead tests be reported to the state and not just levels => 20mcg/dL. The number of reported screenings for FY 2000 was 137,536 and for FY 2001 was 149,233. As stated previously, despite the increased screenings the decline in EBLLs continued dramatically (an 18% decline in children with EBLLs => 10 mcg/dL and a 27% decline in children with EBLLs => 20mcg/dL.) The answer to the question "Do these reported declines represent actual declines in EBLLs among high-risk children?" will revolve around the extent to which the screenings remained targeted. Were there changes to the social context of the high-risk population of children or their environment that could have affected whether high-risk children were screened for lead poisoning?


What follows develops the hypothesis that on the one hand, the population of high-risk children actually screened from July 1, 1999 through June 30, 2001 declined dramatically as the result of the implementation of Temporary Assistance to Needy Families (TANF) and its attendant decline in Medicaid rolls. On the other hand, the decline was masked by the passage of NJ’s Universal Screening Law and the increased enrollment of children in NJ KidCare, both of which would have the effect of increasing screenings while not necessarily reaching targeted populations. According to a GAO report already cited, 80% of EBLL children are Medicaid eligible. Thus changes to the demographics of Medicaid enrollment deserve scrutiny in the assessment of the significance of reported declines in EBLLs.

For NJ DHSS Report 2000, the first year when all blood lead tests in the State were reported, not only is there a decline in the number of EBLLs across all categories but the rates per children screened also declines. New Jersey HCFA-416 report for FY 1999 indicated a total of 20,056 lead screenings for children one through five years of age. For this age group, the rate of screening was 14.5 % (141,075 eligible for lead screening).9 In this period, NJDHSS reported 1603 EBLLs =>20mcg/dL for all children tested. NJ HCFA Report–416 for FY 2000 saw a marked increase in EPSDT lead screenings to 36,810 for ages 1 through 5, representing a screening rate of 25% (145,788 eligible for lead screening). Our NJDHSS Report 2000 indicates 1309 children with EBLLS =>20 mcg/dL out of a total of 135,572 children tested.

1999 135,572 children tested 1603 found with EBLLS =>20 mcg/dL Rate = 14.5%
2000 145,788 children tested 1309 found with EBLLS =>20mcg/dL Rate = 25%
What’s wrong with this picture?


The Trend Continues: As already noted, the Report 2001 cites an increase of 11,697 screened in FY 2001 for a total of 149,233 identifying 947 with EBLLS of =>20 mcg/dL. The easy interpretation of the data is that there actually has been a real decline not in just reported EBLLs but in EBLLs statewide including high-risk populations. Because it affects those least able to fend for themselves, our children, this is a conclusion that cannot be accepted without explanation and validation. Other hypotheses must be advanced and tested. Since childhood lead poisoning and Medicaid eligibility are so closely correlated, one is compelled to look at changes to the Medicaid population for answers.10


From 1994 through 1996, a significant percentage of the lead screened population was enrolled in Welfare, Aid to Families with Dependent Children (AFDC). Welfare enrollment carried with it automatic participation in Medicaid. With the passage of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), TANF, the program that replaced AFDC, and Medicaid were de-linked.11 TANF recipients had to formally apply for Medicaid and despite provisions in welfare reform law designed to assure continued and even extended Medicaid coverage, TANF resulted in significant numbers of Medicaid recipients losing coverage. Denial of Medicaid benefits associated with Welfare de-linking was deemed of sufficient magnitude to prompt HCFA’s Director to require states to determine the extent of their individual problems and to take measures to re-instate coverage, as required by law, that was improperly terminated.12

Nationally, for adult women who leave welfare slightly less than half are enrolled in Medicaid six months after leaving. After a year or more off welfare this percentage decreases to less than a quarter and about one half have no health insurance at all. For the children of these women, Medicaid coverage remains strong six months after leaving welfare at 75% but after a year or more less than half of these children have Medicaid coverage and almost one third have no health insurance at all.13 This increasing decline over time is a function of the terms under which Medicaid can be retained, including time limits for transitional Medicaid coverage, face-to-face interviews, complicated application processes requiring difficult to obtain information, and inadequately trained caseworkers.14

Work First New Jersey (WFNJ) is New Jersey’s embodiment of TANF. WFNJ has been immensely successful in reducing the welfare caseload by 64% from 96,500 families in April 1997 to 42,000 families in July 2001. This reduction has entailed a reallocation of Division of Family Development resources (DFD) from dispensing cash benefits to the development of programs designed to put "work first." DFD went from disbursing 75% of its budget in cash benefits in 1995 to 20% in cash benefits in 2001.15 While the TANF caseload has been declining so also has Medicaid enrollment.16 A Families USA study has set New Jersey’s decline in adult Medicaid Coverage at 30% from January 1996 to December 1999.17 For NJ’s children the decline in Medicaid coverage was 6% (-22,434) from 1996 to 1999.18 It should be noted that the decline was ameliorated by expansion of Medicaid eligibility for children 6 through 18 years of age. Thus, the 6% overall decline reflects a sharper drop in Medicaid coverage for that population at high risk of childhood lead poisoning.

According to a November 16, 2000 Mathmatica Policy Institute study,19 commissioned by the NJDHS, the proportion of WFNJ clients who are uninsured or not receiving Medicaid despite eligibility has increased over time.20 This comports well with national data. Concerning the health insurance status of WFNJ employed and unemployed adult leavers, Mathmatica reports that 54 % did not have Medicaid coverage, of which 36% were uninsured and 17% were privately insured. Of these adult leavers without Medicaid coverage 57% recalled that they lost Medicaid at the time they were enrolled in WFNJ; others reported losing Medicaid at varying time spans from WFNJ enrollment. But only 13% left Medicaid after 18 months on WFNJ.21 This is important because it points to a deficient enrollment as responsible for these WFNJ leavers not having Medicaid coverage despite eligibility. Sixty seven percent (67%) of all WFNJ clients had at least one child 5 years or less.22 This last fact is important because it connects this population with Blood Lead Screening requirements.

Forty-one percent (41%) of the children of WFNJ did not have Medicaid coverage, of which 27% had no health insurance at all and 14% were privately insured.23 These percentages combine data for the children of employed and unemployed WFNJ leavers.


We must now calculate the number of children who would be less likely to receive blood lead testing than they otherwise would either through universal lead screening and routine medical care or through Medicaid’s Early and Periodic Screening, Testing and Diagnosis (EPSDT), had WFNJ not been implemented. WFNJ leavers represented 2/3 of the WFNJ caseload, 41% of whom were employed and 25 % unemployed. Although the Mathmatica studies do not provide the actual numbers their survey percentages represent, it’s possible to supply the data from Administration for Families and Children (AFC) records. In July, 1997 (WFNJ’s start date), the number of families enrolled in WFNJ was 95,167. The average number of children in these families was 1.9 for a total of 180,817 children.24 From this number are subtracted 25,909 children who live in families with no adult WFNJ recipients. These children are excluded because they are much less likely to lose WFNJ benefits than the other children.25 The total number of children in July 1997 at risk of being removed from WFNJ was 154,908. Approximately 37% of these children were from birth to less than six years of age.26 Thus for purposes of relating the data to blood lead screening the number of children of concern is 57,316 (37% of 154,908). Reduction in caseloads from July 1997 to January, 2000 by 2/3 means that 38,172 (2/3 of 57,316) were removed from the WFNJ rolls. These are the children of the adults Mathmatica refers to as WFNJ leavers. For a variety of reasons, they are, to varying degrees, less likely to have been screened for elevated blood lead levels than children enrolled in AFDC in earlier years.


UNINSURED CHILDREN. Overall 27% of the children of WFNJ leavers were uninsured.27 The lack of insurance is a powerful disincentive to health care and it is highly unlikely that their children were screened for EBLLs. There is good evidence that high numbers of uninsured children lack a regular care source: "Almost one quarter (23%) of these uninsured children lacked a regular source of care, compared with about 6 percent of the Medicaid enrolled. In fact, only 28 percent of the uninsured reported lack of need as their main reason for not having a regular source of care, while 56 percent cited lack of insurance…. Medicaid eligible uninsured children were almost three times as likely to have an unmet health care need during the year as Medicaid-enrolled children – and almost four times as likely to delay care due to cost."28 The actual number of uninsured children represented by Mathmatica’s survey percentages is 10,307 (27% of 38,172).

THE WORKING POOR. Eighteen percent (18%) of the children of employed WFNJ leavers were privately insured and 59 percent were on Medicaid. (For the children of unemployed leavers private insurance drops to 8% and Medicaid enrollment increases marginally to 60%.)

The number of children of employed WFNJ leavers with private or public insurance is 18,233.29 The majority of the employed leavers are commonly referred to as the "working poor" and what is not clear is to what extent the working poor are able to avail themselves of routine health check-ups, including blood lead screenings. Intuitively, one would surmise that routine doctor visits for the privately insured, employed TANF leavers would be significantly below such care for those children who do not live in poverty. The evidence points in that direction. Employed TANF leavers are usually single, head of household women. They often underutilize support benefits available to them, including food stamps and child care, their employment is often unstable, low wage and too inflexible to allow for taking either themselves or their children for routine doctor visits, and they are often too poor to absorb co-pay expenses associated with most private health insurance offered to low wage workers.30 All of the aforementioned barriers, with the exception of the amount of out-of-pocket medical expense, would apply to employed WFNJ leavers on Medicaid. Lending credence to the proposition that the decline in reported EBLLs is the function of employed Medicaid recipients not using benefits is Medicaid data for FY 1997 and FY 1998. In FY 1997, Medicaid recipients were reported to have received 22,100 total31 EPSDT screenings (not just lead screenings). FY 1998 data show a reduction in total EPSDT screenings 12,317.32 Since the number of Medicaid eligibles increased from one year to the next, this decline of 45% in EPSDT screenings must be a result of a reduction in Medicaid EPSDT usage. This would be in keeping with the proposition that employed WFNJ leavers would be less likely to avail themselves of Medicaid services by virtue of having become members of the "working poor." Since the migration from fee for service to Managed Care was well under way by 1997, it is not appropriate to lay screening declines exclusively at the door of the HMOs as has been done. (See the Report 1999). Usage declines are more likely a result of a combination of these two factors: migration to Managed Care and Employment.

UNEMPLOYED WFNJ LEAVERS. Nor is it clear that unemployed WFNJ leavers enrolled in Medicaid and representing 14,123 (37% of 38,172) children who should have been screened for EBLL are any more likely than their employed counterparts to seek routine health care. The unemployed leavers are significantly worse off than employed leavers. Most do not have the benefit of a stable source income, since they are off of welfare and unemployed. Those that have a stable source of income are on SSI (10%) or are living with an employed spouse or partner (20%). Another 20 % cycle between work and welfare and happened to be unemployed at the time of their interview with Mathmatica. Most alarming is the condition of 50% of these unemployed WFNJ leavers representing 7062 children who should have been screened for EBLLs. These unemployed leavers had no substantial source of financial support, low-level employability characteristics (limited work histories, less education, longer welfare histories). These leavers also tended to have poor mental health with more than half ranking in the bottom quartile nationally on a standardized mental health index.33

As stated, 1/3 of the children of unemployed WFNJ leavers were uninsured. These children were already accounted for above. The number of children of unemployed leavers who had either private insurance (8%) or Medicaid (60%) was 9604 (68% of 14,124), children whose likelihood of screening was lessened as the result of WFNJ.


The foregoing establishes a case that 38,172 children who left WFNJ are less likely to have been screened for EBLLS than would have been the case had AFDC never become WFNJ. The decline in WFNJ rolls was not exclusively the result of clients leaving WFNJ. It is also a function of a decline in the rate of new entrants. Harder to quantify is the number of eligible Medicaid children who never made it onto the rolls because of WFNJ diversionary policies. Diversionary practices go hand in hand with a work first philosophy.34 WFNJ employs the following diversionary practices: the requirement that the applicant participate in a job search while the application is being processed. Many applicants do not get past the job search. Many applicants receive assistance through Early Employment Initiative (EEI). EEI offers 60 days of intense job search which may result in the applicant being placed in a job and not going on the rolls at all. The appeal of EEI is a one time, lump sum payment to help with expenses such as rent and car payments. WFNJ’s child support requirement is another disincentive to enrollment.35 The applicant must identify the father(s) of the client’s children, must supply three types of information concerning the father, and if the father has never been legally identified, the mother must establish paternity through the Paternity Opportunity Program (POP). No data was found identifying the number of eligible clients who were deterred from filling out a WFNJ application because they "heard" the process was demanding. The number who participated in EEI and who were eligible and not enrolled in Medicaid should be quantifiable. This is an area requiring further investigation.


There is good evidence that the WFNJ application process resulted in many thousands of Medicaid recipients applying for WFNJ, not qualifying, and then being improperly terminated from Medicaid. Theoretically, this should not happen because even though application for WFNJ and Medicaid are made on one application form, they are separate, unrelated processes. Caseworkers are instructed that termination or denial of WFNJ benefits should have no affect upon the Medicaid portion of the application. In many instances WFNJ and Medicaid applications were not separated.

A HCFA visit to New Jersey in 1999 to evaluate the relationship between Medicaid enrollment and Welfare Reform reported on a NJ DEPARTMENT OF HUMAN SERVICES "churning study" designed to gain insight into the decline in Medicaid and AFDC/TANF eligibility since January 1993. The "churning study" involved the creation of a database of 68,000 children who were terminated from Medicaid for reasons other than reaching the age of 21. All terminated children fell into one of four categories:

The HCFA report also cited an Arthur Andersen/Robert Wood Johnson Study designed "to diagnose key problems and opportunities for change in the New Jersey Medicaid Eligibility System." Applying the Andersen/RWJ study to the "churning study" data, the HCFA report states:

At the time of the study [Andersen/RWJ], it was found that TANF workers were not as knowledgeable as they should have been about eligibility rules, resulting in some misinformation being given to clients. For example, applicants were not always made aware that the requirements for Medicaid eligibility were different from those for cash assistance. This misinformation may have contributed to the high number of "non-compliance" terminations. [emphasis added].37

Although the time frame of the churning study (1993–1999) does not exactly coincide with the time frame of this Review, the number of children improperly terminated from Medicaid rolls is 55,080 (81% of 65,000). Not all of these children would have been in the age group from birth to less than six years that should have been screened for EBLLs. If we apply AFC data to this group of children, as we did above for WFNJ children leavers, then we can estimate that 37% were from 1-5 years of age and consequently we must add 20,380 children to the group that would be less likely to be screened had WFNJ not been implemented.

The HCFA report and the Andersen/RWJ study it cites both make reference to problems with enrollment into Transitional Medicaid programs.38 The Andersen/RWJ study makes reference to caseworkers not always determining whether the client qualifies for other categories of public health insurance when Transitional Medicaid ends. The HCFA report cites a NJ study that indicates that 10% of WFNJ clients who should get Transitional Medicaid Assistance do not get it and that "DFD and DMAHS were developing a joint outreach project at the time our review was conducted, in order to reach 10% (currently estimated to be about 26,000 families) of potential transitional clients who were found not to be receiving transitional Medicaid."39 With the most conservative interpretation of this data we calculate that 1827 children must be added to the number of children less likely to be screened for EBLLs.

Thus far we have identified 38,172 children of adult WFNJ leavers who are believed to have a reduced chance of having a BLL screen by virtue of being no longer enrolled in WFNJ and being uninsured, or members of the "working-poor" on Medicaid, or unemployed on Medicaid but extremely disadvantaged. We have also identified 20,083 children of WFNJ applicants improperly terminated from Medicaid and at least 1827 who were improperly denied Transitional Medicaid Assistance, who are also believed to have a reduced chance of being screened for an EBLL than would have been the case had they applied for welfare under AFDC prior to July 1997. All of these children would have one or more of the characteristics identified in National Health and Nutrition Examination Survey (NHANES) III data that would place them at significantly higher risk of EBLLS. These characteristics are: ethnicity (Afro-American and Hispanic), residence in densely populated areas, low income, and residence in older housing stock. (Although we have no specific housing information for the children identified in this review, it is assumed that most live in older housing stock that contains lead-based paint (LBP). The older the residence the more likely it is to contain LBP. Seven of the more populous of New Jersey’s 21 counties have over 40% of their housing stock constructed prior to 1950.) From a GAO study based upon this NHANES data we know that 83 % of EBLLS => 20mcg/dL is correlated with Medicaid eligibility. Given the targeted nature of childhood lead poisoning, there is a strong possibility that the decline in reported EBLLS is the result of large numbers of high-risk children not being screened. 


The next issue that needs to be addressed is the decline in reported EBLLs in the context of the increased rates of screening from FY 1999 to FY 2000 (see above page 10). It should be recalled that this review has established that despite the decline in reported EBLLs from FY 1995 through FY 1999 the rate of EBLLs per number of children screened appears to have increased not decreased. (pages 8-9). Thus we are talking about declining rates for only two years, FY 1999 and FY 2000.


The increases in the number of children screened for lead poisoning from FY 1999 through FY 2000 is probably the result of two simultaneously occurring events: the addition through NJ KidCare Plans B, C, and D of the over 50,000 children to the ranks of the insured and the emerging compliance with New Jersey’s Universal Lead Screening law (Public Law 1995, chapter 328). Regulations implementing this law (N.J.A.C. 8:51A) became effective December 1, 1997. Universal screening is also the most plausible way of explaining increases in the number and rate of Medicaid EPSDT blood lead screenings between FY 1999 and FY 2000.40, 41, 42

NJ KidCare: As part of the Balanced Budget Act of 1997, US Congress adopted Title XXI of the Social Security Act that created State Children’s Health Insurance Programs. SCHIP is designed to provide health coverage to children of working parents or other low-income households who do not have employer-sponsored health insurance or who do not quality for Medicaid. Shortly after SCHIP became law in January 1998, 41 states implemented their own CHIP programs. They had three choices for implementation: 1) Medicaid eligibility expansion, 2) stand-alone and separate from Medicaid, 3) a combination of Medicaid expansion and a stand-alone program. NJ KidCare was approved April 27, 1998 as a combination program. The Medicaid expansion segment of NJ plan took effect February 1, 1998. The stand-alone program went into effect March 1, 1998. Medicaid Expansion (NJ KidCare Plan A) extended benefits to children age six through eighteen whose families were not above 133% of FPL. Though comprising a large number of children, 38,673, the addition of these children should not have had appreciable effect on the population of children who would require blood lead testing. They would, however, be accounted for on Medicaid rolls and not on the rolls of the stand-alone program.

New Jersey’s stand-alone children’s insurance program, NJ KidCare, by law is designed to service those children who do not qualify for Medicaid. Enrollment in NJ KidCare involves a determination of Medicaid eligibility.43 From implementation in March 1998 through FY 2000, 50,361 children have been enrolled in NJ KidCare Plans B, C, and D. These children would have been enrolled if they did not have private insurance and had incomes not exceeding 350% of the FPL. The addition of these children to the rolls of New Jersey’s insured children would increase the pool of children likely to be screened for EBLL. By virtue of their economic status in relation to FPL, these children would not have, in as pronounced a fashion, the characteristics representative of the concentrated, localized nature of children with EBLLS.


New Jersey’s universal lead screening law requires that all children in the state be screened for childhood lead poisoning at least twice in the child’s early years: between 9 and 18 months of age, preferably as close as possible to 12 months and between 18 and 26 months, preferably as close as possible to 24 months with this second test performed no more than six months after the first test. In addition, children who had been screened but as the result of a risk assessment are determined to be at high-risk from a new source of lead exposure will be re-screened. Children under the age of six who had never been screened will also be screened.

The fact that universal screening is a state wide law applying to all age-appropriate children, regardless of economic status, would have the effect of increasing the number of children screened44 while not necessarily targeting high-risk children. Eliminating high-risk children from the pool of children who should be blood lead tested in combination with universal screening, would have the effect of increasing screening rates while decreasing the number of children identified with EBLLs. Universal screening is also the most plausible way of explaining increases in the number and rate of EPSDT blood lead screenings between FY 1999 and FY 2000, since what was occurring statewide could not help but affect the Medicaid population and indeed was probably more prevalent in that population.


There is a strong probability that the decline in EBLLS is attributed to the transformation of AFDC into WFNJ and that those declines within the context of screening rates are the result of New Jersey’s Universal Screening Law and the significant increase in insured children through NJ KidCare plans B, C, and D.

Policy Recommendations

Increasing screening does not necessarily better identify EBLL children. Universal screening in combination with intensive targeting is the surest approach to identifying children with EBLLS. This Review has identified WFNJ leavers as an identifiable and targetable group at high-risk of EBLLS that current screening practices has most likely missed. Many of the initiatives taken by the NJ DHSS and NJ Division of Human Services will probably prove effective in improving the performance of HMOs and fee-for-service physicians in administering blood lead tests. These initiatives include changes to HMO contract language, the implementation of a pilot project in Trenton to assess rates of screening and develop measures for improvement, and ACLU initiated activity for additional pilot projects for lead poisoning awareness in Irvington and Camden funded at $ 150,000 through former Acting Governor, Donald DiFrancesco’s "Kid’s Needs" program. These initiatives are necessary parts of the solution but without targeted outreach they may serve, as the Universal Screening Law, to increase screening rates but not the identification of EBLL children. This is because WFNJ leavers are either uninsured or, if insured, members of the "working poor", and if not members of the working poor, then likely to be highly disadvantaged. EBLL children are under-reported not because they are not screened for blood lead testing in the doctor’s office but because they infrequently get to the doctor’s office, if at all. The targeting that will be most effective is that which reaches directly the affected populations and makes the health services they need more available to them. How might this be done?

The uninsured WFNL leavers should be directly contacted. The majority of them are uninsured, not because they are ineligible for public insurance, but because of the transformation from AFDC to WFNJ. The State has a special obligation to them and especially to their children. They should be located and enrolled in Medicaid, a process that should already be taking place as required by a HCFA directive.45 Incentive for enrollment could be enhanced by special enrollment days at appropriate centers and cash stipends to defer the client’s transactional expense (e.g., travel, child care.). New portable blood lead screening technologies would allow blood lead testing to be performed on site for children who accompany their caregivers.46

One of the important accomplishments of NJ DHSS and NJ Division of Human Services was the joint application of LEAD MATCH software that allowed the comparison by name and other key identifiers of DHSS’s lead testing database with Department of Human Services Medicaid database. The use of this software may be used to determine which Medicaid insured WFNJ leavers, both employed and unemployed, received blood lead tests. Thus, it can be used to test one part of the hypothesis of this Review. It can also be used to refine the selection process by identifying those WFNJ leavers who did not receive blood lead tests.

For the insured "working poor" WFNJ leavers and for the insured unemployed WFNJ leavers, special outreach educationals and incentives should similarly be developed. It should be noted that for all WFNJ leavers the under-utilization of services extends to child- care, food stamps and probably immunization. Outreach to this group might require a multi-programmatic approach.

The principle of targeting should also be applied within the affected group. Their data should be sorted by county, city, zip code, address and census tract and then compared with similar data that shows a high prevalence of EBLLs by corresponding location. Special outreach might then be accomplished by neighborhood and then by hot spots within neighborhoods. Outreach as described above could be undertaken but only with the addition of individual client or location contact information coordinated perhaps through the Local Health Department. It may very well be that for the State of New Jersey as for the city of Providence, Rhode Island the percent of the properties causing EBLLs is surprisingly small. (Rhode Island percent of properties causing EBLLs = 2%.) Current and historical data would certainly indicate that high percentages of EBLLS are found in Essex County and within Essex County, the City of Newark and other densely populated cities whose populations have large numbers of Medicaid eligible children.

The above approach to identifying EBLL children, targeting within targeted groups by location, should be seen as an attempt, though modest, to integrate primary and secondary preventions, the former seeming to have lost all currency.47 Primary lead prevention should be realized by relating location data to existing housing code violations and by prioritizing identified locations that have produced EBLL children for housing code violation inspection.48 Vigorous enforcement by local construction officials must be part of this program. Implementation of primary interventions is long overdue.

The same approach should be taken for the 20,083 children identified in this Review, children whose parent was improperly terminated from Medicaid upon applying for WFNJ and being found ineligible. The 1827 children whose parent was denied Transitional Medicaid Assistance should be included in this group. HCFA Director Westmoreland in his letter to State Medicaid did not require that these individuals be found and enrolled as he did for those who lost TANF benefits but he strongly suggested that the states take that approach.49


Finally, the first two NJ DHSS Reports for FY 1998 and 1999 emphasized the highly targeted nature of childhood lead poisoning among ethnic minority children. The last two reports emphasize the universality of childhood lead poisoning because all counties reported at least one case of an EBLL => 20mcg/dL. The universality of childhood lead poisoning is forgotten at our peril. But universality does not replace the targeted nature of this entirely preventable childhood disease. In short, there is no more important an environmental justice issue than childhood lead poisoning. This emphasis should find its way back into future NJ DHSS reports.

The first two reports also mentioned that DHSS’s estimate statewide of the number of children with EBLLs => 20 mcg/dL as in excess of 6000 children. These estimates have been dropped from the last two reports without explanation. Lacking documentation that reported declines in EBLLs reflect actual statewide declines, there is no basis for eliminating these estimates. It is important to get straight on this issue and other issues raised in this Review because our perceptions of childhood lead poisoning in New Jersey and our policy decisions, including resource allocation, are greatly fashioned by these NJ DHSS Annual Reports.


1. For example, the significance of new data on the percentage of residences abated in the fiscal year they poisoned children as compared to the percent of residences abated over an extended time period. The significance of the atypically higher blood lead levels among NJ’s 5 and 6 year olds. And the fact that a case of childhood lead poisoning is closed not upon confirmation of consecutive blood lead tests below 10 mcg/dl as recommended by CDC but upon completion of abatement as attested by the Local Health Official.

2. Childhood Lead Poisoning in New Jersey — Annual Report — Fiscal Year 2001 (July 1, 2000-June 30, 2001, page 11.

3. Childhood Lead Poisoning in New Jersey — Annual Report — Fiscal Year 1999 (July 1, 1998-June 30, 1999, page 20.

4. CDC in its December 22, 2000 Report does speculate that the construction of new housing and the renovation and demolition of older housing stock may have contributed to the 19 state decline in EBLLS. CDC cites US sources indicating that the percentage of low income children living in pre-1940s and 1940-1970 housing declined 31% and 14% respectively with the number of low income children living in post-1974 housing increasing by 5%. (See: President’s Task Force on Environmental and Health Risks and Safety Risks to Children. Eliminating Childhood Lead Poisoning: a federal strategy targeting lead based paint hazards. Available at http://www.epa.gov/children/whatwe/leadhaz.pdf.) The 2001 Report simply re-issues 1990 Census of Housing and Population data indicating the number of units and the % of total units built pre-1950. with a note that the 2000 Census data is not yet available. Whether changes to the quality of housing stock through renovation and demolition and the building of new housing has had an effect on the numbers of EBLL children in New Jersey is a area that requires closer scrutiny. A good place to begin would be the City of Newark and other cities which have seen significant demolition of their public housing stock. Since the NJ DHSS has good historical data on EBLL children this should not be that difficult.

5. MMWR Weekly Report, "Recommendations for Blood Lead Screening of Young Children Enrolled in Medicaid: Targeting a Group at High Risk." December 6, 2000/Vol. 49/ No. RR-14.

6. Childhood Lead Poisoning in New Jersey Annual Report, Fiscal Year 1999 , page 20.

7. United States General Accounting Office (GAO), "Lead Poisoning: Federal Health Care programs Are Not Effectively Reaching At-Risk Children," January 1999. The 39% rate is from a GAO follow-up audit of 15 states.

8. Inexplicably the Report 1998, Table 1 column "Percent >= 10ug/dL" includes the next column "Percent >= 20 ug/dL" for a total percent of all children with EBLLS of 14.5%. The same types of data are presented differently in the Report 1999 with the same columns being separated. This allows the "Percent>= ug/dL" to be reported as 13% because it excludes the next column "Percent >= 20ug/dL as 3%. Thus the increase from one year to the next is not readily discernible.

9. Author’s calculation. This calculation does not include children from 0-1 year of age. To have included this category would have decreased the rate of screenings unfairly. The entire category and the small number of blood lead tests performed on this age group were eliminated from the calculation. This also applies to FY 2000 data and its screening rate of 25%.

10. According to a draft report that matched Medicaid enrollment records with DHSS total reported blood lead tests, FY 2000 saw a substantial increase in the percent of under three year old Medicaid children screened to 29%.

11. The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWOR) replaced AFDC with Temporary Assistance To Needy Families (TANF). TANF requires recipients to work after two years of assistance. It limits cumulative lifetime benefits to 5 years. TANF recipients must perform "work activities," including subsidized or unsubsidized employment, on-the-job training, community service, or up to 12 months of vocational training, to maintain benefits. Reform includes provisions designed to assure that children, pregnant women and low-income families do not lose Medicaid coverage as a result of the welfare changes. This is done by maintaining Medicaid eligibility for all families that would have qualified under AFDC rules in effect on July 16, 1996. Transitional Medicaid assistance is provided to allow low-income families that receive Medicaid to continue coverage for a period of 4 to 12 months if they have earnings or child support income that would otherwise make them ineligible for Medicaid. Coverage for children who were born after September 30, 1983 and who are in families with incomes under federal poverty guidelines is also maintained.

12. Letter to all State Medicaid Directors dated April 7, 2000 from Timothy Westmoreland.

13. Garrett, Bowen and Holahan, John, "Welfare Leavers, Medicaid Coverage, and Private Health Insurance," The Urban Institute, New Federalism, Series B, No. B-13, March 2000, pages 1-2. This brief presents data on adult women who left welfare from January, 1995 and who were not on welfare at the time of their interview February through November 1997. Those interviewed represent 1.2 M women nationwide. The number of children represented by this data is 2.9 M, not an insignificant number. 1,537,000 children did not have Medicaid coverage one year after leaving welfare and 1,363,000 did. 871,000 had no health insurance at all. 783,000 had private insurance.

14. For children who left welfare, their caretaker employment status has an effect on health insurance. 47% of children of caretakers with jobs are enrolled in Medicaid. Another 33% of these children are covered by private insurance policies. 24 % are without health insurance at all. Children of non-working caretakers are more likely to be Medicaid enrolled (55%), are less likely to be insured privately (18%), and more likely to be uninsured (28%).

15. Family income is another important factor affecting this discussion. 57% of the women who leave welfare have family incomes below the FPL. Of these only 44% have Medicaid coverage a surprisingly low figure given their eligibility, only 14% have private insurance, and a very large 43% are uninsured.

16. Dion, Robin M and Pavetti, LaDonna, Access To and Participation In Medicaid and the Food Stamp Program: A Review of Recent Literature, March 7, 2000, Mathmatica Policy Research, Inc., Washington, DC. Pages 8-12.

17. Press Release, NJ DHS, Office of Public Information, July, 2001.

18. Declines in Medicaid enrollment are attributed mainly to an improved economy and to implementation of TANF. Which is principally responsible is hotly debated? See the footnote 13 below.

17. Go To Work, Do Not Collect Health Insurance: Low Income Parents Lose Medicaid, at http://familiesusa.org/media/reports/gowrk.htm, page 3.

18. One Step Forward, One Step Back, Children’s Health Coverage after CHIP and Welfare Reform, Families USA, Washington, DC, p.17. In the same period there were added to the NJ KidCare ( NJ’s version of the federal Children’s Health Insurance Program ) 10,061 children for a total increase of 2.7%. One would like to think that children knocked out of Medicaid would be picked up again under NJ KidCare but this is unlikely to any great extent since meeting Medicaid’s income eligibility requires Medicaid enrollment. NJ KidCare was designed for uninsured children who do not meet Medicaid requirements. Further, I have not been able to locate data indicating whether the decline of 22, 434 was weighted toward any particular age groups.

19. Current and Former WFNJ Clients: How Are They Faring 30 Months Later?, November 16, 2000, Anu Rangarajan and Robert G. Wood, Mathmatica Policy Research. This study was based upon interviews with 1600 WFNJ clients. The WFNJ leavers represent about 2/3 of the entire caseload. Of the leavers, 41% were employed and 25% were unemployed.

20. This is clear from a comparison of Mathmatica’s first report, How WFNJ Clients Are Faring Under Welfare Reform: An Early Look, pages 30-31, with the second report, Current and Former WFNJ Clients: How Are They Faring 30 Months Later?, pages 75-80.

21. Ibid, page 77.

22. Ibid, page 8, Table 1.3.

23. Current and Former WFNJ Clients: How Are They Faring 30 Months Later?, pages 75-76.

24. Source: National Emergency TANF Datafile as of 12/9/98. TABLE 2

25. 20.8% of the 95,167 cited had no adult recipients and consequently were associated with no adult who was at risk of losing benefits and were themselves then less likely to lose benefits. The actual number of children in these no adult recipient families was 35,557. By July of 2001, approximately 25,909 of these children remained on WFNJ. The number removed from the rolls was 9648. Thus the number of children excluded from these calculations was 25,909. Source: National Emergency TANF Datafile, July-September 1997 and Table 3. See also data supplied by the Center for Law and Social Policy (CLASP) at http://www.clasp.org/pubs/TANF/FY01%20Caseload%20Data.htm.

26. Ibid, Table 22r.

27. Rangarajan, Anu, Current and Former WFNJ Clients, p. 75. Twenty-four percent (24%) of the children of employed WFNJ leavers were uninsured. For unemployed leavers the percentage is 33. The combined percentage is 27 %.

28. Guendelman, Sylvia and Pearl, Michelle, "Access and Health Care use in Children of Working Poor Families: Reducing Disparities Through Insurance Coverage," The 128th Annual Meeting of APHA.
Davidoff, Amy J, et al ,"Children Eligible for Medicaid but Not Enrolled: How great a Policy Concern?," , The Urban Institute, Series A, No. A-41, September 2000, p.3.

29. The children of employed WFNJ leavers represent 62% of all children leavers 23,666 (62% of 38,172). Seventy-seven percent (18% + 59%) have privately or public insurance (18,233)or (77% of 23,666).

30. Is Work Enough? The Experience of Current and Former Welfare Mothers Who Work, Denise F. Polit et al, Manpower Demonstration Research Project, November 2001. The data cited here is laced throughout this excellent report, which is all the more compelling because of its presentation of individualized illustrative case histories.

31. "Medicaid Recipients By Type of Service — Fiscal Year 1998," TABLE 3. Source Medicaid Statistical Information Systems, HCFA, CMSO, HCFA-2082 Report, August 16, 1999. Not only is the large decline in EPSDT Screenings surprising (45% from FY 1997-FY 1998) but also the small number of total screenings for each year.

32. "Medicaid Recipients By Type of Service — Fiscal Year 1998," TABLE 3, Source Medicaid Statistical Information Systems, HCFA, CMSO, HCFA-2082 Report, January 27, 2000.

33. Rangarajan, Anu, Current And Former WFNJ Clients, pages xxi-xxiii.

34. Dion, M and Pavetti, LaDonna, "Access To and Participation In Medicaid and the Food Stamp Program," Mathmatica Policy Research, Inc. page 11.

35. Not all would agree that the child support requirement was a diversionary practice. Whatever the name, the potential effect on enrollment remains.

36. HCFA New York Regional Office, "Medicaid Welfare Reform Implementation Review: New Jersey," February 14, 2001, page 19.

37. HCFA New York Regional Office, 20.

38. HCFA New York Regional Office, pages 10-11. "Under federal requirements, States must provide up to twelve months of transitional Medicaid to families under certain conditions. States must provide six months of coverage to families who lose Medicaid under Section 1931 (b) due to excess hours or earnings from employment of the caretaker relative, or because a member of the family lost the applicable disregards. States must provide an additional six months of coverage when the family income remains below 185% of the federal poverty level (FPL). New Jersey meets these requirements and exceeds them by providing transitional Medicaid for individuals no longer Medicaid-eligible under Section 1931 for up to 24 months."

39. HCFA New York Regional Office, pages 11-12. Should the inattention to transitional Medicaid benefits affect 26,000 families, then the effect upon screening for childhood lead poisoning could be considerable. Despite the grammatical construction, the 26,000 families probably refers to the total number of families that could have received transitional benefits with 10% or 2600 being the object of outreach. Assuming 1.9 children per family, the number of children of concern for our purposes would be 37% of 4950, i.e. 1827 children. The HCFA report does not provide sufficient information to comment further and no published NJDHS has been found. Transitional Medicaid enrollment needs more investigation.

40. From FY1996 through FY 1999, the number of children from one through five years of age eligible for EPSDT screenings declined 7% from 152,126 to 141,075. Only in FY 2000 has an increase been shown (145,788.)

41. No data has been found to substantiate that the universal screening law has finally "kicked in" to increase screening rates. But significant resources have been expended publicizing its requirements.

42. NJ DHS has verified that HCFA-416 reports do not include NJ KidCare Plan B, C, and D plan children. However, the author of the ‘Lead Match" study has verified that data reported as "Medicaid" included NJ KidCare plans A, B, and C.

43. Ellis, Eileen, Medicaid Enrollment in 21 States: June 1997-June 1999, pp 57-58. One would expect some increase in New Jersey in conventional Medicaid enrollment (Title XIX) of children one year of age or less up to 185 % of FPL and other children from 1 through 5 years of age up to 133%of FPL along with the addition of children 6 to 19 years of age through Medicaid Expansion (Title XXI) up to 133% of FPL. This may indeed be the case but controlling for Medicaid Expansion under Title XXI, the number of enrollees in non-expanded Medicaid (Title XIX) has actually declined. NJ KidCare enrollment may be having the ancillary effect of increasing Medicaid rolls other enrollees are leaving at a slightly higher rate.

44. NJ KidCare Plan B, C, and D children are entitled to all or most EPSDT services, including tests, depending on Plan. Framework For State Evaluation of Children’s Health Insurance Plans, submitted in compliance with Title XXI of the Social Security Act (Section 2108 (b), Contact person: Michelle Walsky, Executive Director, Office of NJ KidCare, Chart Plan A,B, and C Services.

45. These are the parents and children whom HCFA Director Westmoreland refers to in his letter to State Medicaid Directors: "States must determine whether individuals and families lost Medicaid coverage when their TANF case was closed, or when their TMA coverage period ended without proper notice or without a proper Medicaid redetermination…., " page 2.

46. CDC, "Recommendations for Blood Lead Screening of Young Children Enrolled in Medicaid," MMWR, 4/15/01, page 11.

47. Needleman, Herbert L, "Childhood Lead Poisoning: the Promise and Abandonment of Primary Prevention," AJPH, 1998: 88, 1871-1877.

48. The literature on targeted approaches to childhood lead poisoning is growing the following were consulted for this section of the review:
• Morin, Richard P, "The Lead Heads," Brown Alumni Magazine, May/June 1999.
• Sargent, J.D., et. al., "Childhood Lead Poisoning in Massachusetts Communities: Its Association With Sociodemographic and Housing Characteristics," AJPH, Vol. 85, Issue 4, pp. 528-534.
• Lanphear, B.P., et al, "Community Characteristics Associated With Elevated Blood lead levels in Children. Pediatrics 101; 264-271.
• Sargent, J.D., et al, "The Association Between State Housing Policy and Lead Poisoning in Children,’ AJPH, Vol. 89, Issue 11, pp 1690-1695.
• Brown, Mary Jean, et al. "The Effectiveness of Housing Policies in Reducing Children’s Lead Exposure," AJPH, Vol. 91, No. 4, pp 621-624.

49. Westmoreland, page 3.

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