Responding to the Flint Michigan Water Crisis: What is the Role of Medicaid?

Today I had the opportunity to testify before the House Energy and Commerce Health Subcommittee on lessons emerging from the Flint water crisis. I wish the hearing hadn’t been necessary but I hope Flint is a wake up call to reexamine our nation’s policy on lead and children’s health. I am concerned not just about the health of children in Flint but about around the country who are at risk of high levels of lead exposure.

It was an honor to testify along with pediatrician Dr. Mona Hanna-Attisha, a true hero who stood up for the children and families in Flint to demand action.

I told the committee that while there is more than enough bad news to go around, there is one small bit of good news as a result of the Flint water crisis. Governor Rick Snyder and President Obama’s Administration were able to come to bipartisan agreement on a Section 1115 Medicaid waiver very quickly. At a time of sharp partisan discord, it was good to see this bipartisan agreement, which relied on Medicaid to respond to the health needs of children and pregnant women in Flint. CMS approved the waiver on February 28, just 14 days after the Governor submitted it. Now it is awaiting approval by the Michigan State Legislature.

It is not surprising that Medicaid was such a critical component of the Governor’s response. Medicaid’s flexibility and financing structure make it a very popular program for Governors and others to turn to in times of need. Medicaid was a crucial component of state and federal response to previous emergencies such as 9/11 and Hurricane Katrina. Because Medicaid funding is not capped, Medicaid is able to respond to unanticipated emergencies whether they are natural disasters and man-made.

The Flint waiver includes an expansion of Medicaid and the Children’s Health Insurance Program (CHIP) for children and pregnant women with incomes up to and including 400 percent of the federal poverty level who were served by the Flint water system during a specified time period. Children and pregnant women above those income levels will be able to purchase or buy-in to public coverage if they wish to do so, and CHIP premiums will be waived for those who are CHIP eligible. Children will retain coverage until age 21, and targeted case management services will be offered to families in Flint. It is estimated that an additional 15,000 persons in Flint will be newly eligible for coverage as a result. One omission in the waiver agreement is that only children who are citizens are eligible.

And for children in situations such as that which has emerged in Flint, Medicaid’s comprehensive pediatric benefit (Early Periodic Screening Diagnosis and Treatment or EPSDT) is essential. The Medicaid statute requires coverage of laboratory tests including lead blood level assessments appropriate for age and risk factors and once a problem is identified through a screen, the EPSDT benefit requires that treatment must be provided. In addition, children may not be charged premiums or copays in the Medicaid program, which can be a barrier to needed care.

These features of Medicaid made it the obvious choice for Governor Snyder to turn to in responding to the crisis in Flint. In general, his proposal, and the terms and conditions of the waiver were sound. We did submit some specific suggestions for improvements such as covering immigrant children. You can read our full comments on the waiver here.

The Flint water crisis has created an opportunity, and indeed a responsibility, to reexamine Medicaid policy with respect to lead more broadly. In that vein, I suggested that the Committee consider two suggestions:

  • Congress should consider ways to improve lead screening rates in Medicaid. Despite the requirements to screen for lead in the Medicaid program, screening rates are not where they should be. States must ultimately be held accountable for low screening rates, but it is worth noting that most children in Medicaid are receiving services through managed care. Ensuring that managed care plans are held accountable for improving screening rates would go a long way towards ensuring that public health objectives are being met.
  • Congress should review CMS policy which allows states to request exemptions from universal screening requirements. In 2012, CMS established a process by which states can request permission to target lead screenings rather than screen all children in Medicaid. To date, Arizona is the only state that has received permission to move to targeted screenings. Currently Washington and Nevada have such requests pending. Recent events in Flint suggest that this option should be carefully reviewed and perhaps reconsidered. At a minimum, there needs to be a more robust public process for states requesting exemptions from universal screenings requirements similar to the process required for Section 1115 waivers.

Prevention is the key to ensure that such tragedies do not happen again. Screening for elevated blood lead levels for children enrolled in Medicaid is critical for the health of those children and also as a mechanism to identify possible widespread lead exposure. Going forward, a strong Medicaid program is essential for low-income kids who are at greater risk of lead poisoning.

The full hearing record is available at the House Energy and Commerce Health Subcommittee website.