Recommendation: The Administrator of CMS should work with states and relevant federal agencies to collect accurate and complete data on blood lead screening for Medicaid beneficiaries in order to ensure that CMS is able to monitor state compliance with its blood lead screening policy, and assist states with planning improvements to address states' compliance as needed. (Recommendation 1)

Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
Status: Open
Priority recommendation

Comments: In June 2020, Centers for Medicare & Medicaid Services (CMS) officials said that obtaining complete data on blood lead screenings for children enrolled in Medicaid will not be possible, but that the agency is committed to improving the accuracy and completeness of the data. For example, in February 2020, CMS reported that the agency is planning to use a new data system-as states meet certain data quality and completeness benchmarks for the system-to generate the report that includes states' blood lead screening data. CMS stated that this will improve the agency's and states' ability to assess gaps in blood lead screening data. This is a positive step, yet any new data system will also need to consider how to help address known limitations in the current blood lead screening data, such as the under-counting of blood lead screening tests not paid for by Medicaid. To implement this recommendation, CMS should address limitations in blood lead screening data to better monitor compliance with the agency's blood lead screening policy.

Recommendation: The Administrator of CMS should regularly assess the appropriateness of performance measures and targets for the EPSDT benefit, and take any necessary actions to ensure their relevance and use, including adding, changing, or removing measures, or targets, and regularly communicating performance measures and targets to states. (Recommendation 2)

Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
Status: Open

Comments: In June 2020, CMS officials reiterated that they do not concur with this recommendation, in part because the agency does not have the authority to set binding targets for every EPSDT measure. As we stated in our report, our recommendation does not assume that targets should be set for every measure--rather, that CMS needs to regularly assess the appropriateness of performance measures and targets for the EPSDT benefit and communicate them to states. This includes assessments of the CMS-416 performance measures, such as the participant and screening ratios. which CMS officials acknowledge have limitations.

Recommendation: The Administrator of CMS should conduct regular evaluations of state performance by comparing states' performance measurement data with CMS's EPSDT targets to identify gaps in states' performance and areas for improvement. (Recommendation 3)

Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
Status: Open

Comments: In June 2020, CMS officials reiterated that they do not concur with this recommendation, in part because the agency provides states with information about their performance on ESPDT measures reported on the Child Core Set, including a state's performance relative to other states' performance. We noted the limitations of this approach in our report; descriptions of a state's performance relative to other states is subject to change over time. For example, because the median is the midpoint of all states' performance, it ensures that half of states will not meet it, regardless of their individual performance. A fixed target--or targeted improvement goal, such as the one developed as part of the Oral Health Initiative--would provide states with the opportunity to measure performance over prior years' results, which is a more meaningful measure that all states can strive to achieve.

Recommendation: The Administrator of CMS should assist states with planning needed improvements, including providing focused assistance, to resolve gaps in states' performance in meeting CMS's EPSDT targets. (Recommendation 4)

Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
Status: Open

Comments: In June 2020, CMS officials reiterated that they do not concur with this recommendation, in part because the agency does not believe that it is productive or appropriate to set targets for every EPSDT measure. As we stated in our report, our recommendation does not assume that targets should be set for every measure. However, developing additional targets on performance measures critical to beneficiaries' health and well-being could help improve oversight of EPSDT. Targeted technical assistance could be valuable for CMS to provide to states after identifying gaps in states' performance relative to EPSDT targets. Doing so would allow CMS to share additional strategies to help states plan and implement needed improvements.

Recommendation: The Administrator of CMS should develop a plan with time frames and interim milestones for using T-MSIS data to generate the necessary data from the Child Core Set to improve EPSDT oversight and streamline state reporting. (Recommendation 6)

Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
Status: Open

Comments: In June 2020, CMS officials said that they are currently exploring the feasibility of using T-MSIS data to generate certain Child Core Set measures. Specifically, the agency is conducting a pilot with five Child Core Set measures. CMS officials said that they will use the pilot's results to determine the timeline for generating the additional Child Core Set measures through T-MSIS. GAO will continue to follow the agency's progress on this activity.

Recommendation: The Director of HUD's Lead Office should ensure that the office more fully documents its processes for scoring and awarding lead grants and its rationale for award decisions. (Recommendation 1)

Agency: Department of Housing and Urban Development
Status: Open

Comments: As of November 2019, HUD's Lead Office had taken steps to implement this recommendation. For example, they updated the 2018 Application Review Guide with some criteria that could be used to score grant applications. However, the 2019 Application Review Guide did not contain similar criteria. To fully implement this recommendation, the agency will need to follow through and adopt criteria to score grant applications on a consistent basis.

Recommendation: The Director of HUD's Lead Office should ensure that the office periodically evaluates its processes for scoring and awarding lead grants. (Recommendation 2)

Agency: Department of Housing and Urban Development
Status: Open

Comments: As of November 2019, HUD's Lead Office began to take steps to implement this recommendation. For example, in the upcoming weeks and months, the Lead Office staff plan to meet to review the most recent round of grant applications and determine whether any changes need to be made to the scoring criteria for future years. To fully implement this recommendation, HUD's Lead Office staff will need to provide evidence the office is periodically evaluating and changing processes to score and award grants, as appropriate.

Recommendation: The Director of HUD's Lead Office and the Assistant Secretary for the Office of Public and Indian Housing (PIH) should collaborate to establish a plan to mitigate and address risks within HUD's lead paint compliance monitoring processes. (Recommendation 4)

Agency: Department of Housing and Urban Development
Status: Open
Priority recommendation

Comments: As of November 2019, HUD officials told us the agency had taken steps to implement the recommendation, including requiring PHAs to submit appropriate documentation regarding public housing units' compliance with lead paint regulations and updating an internal checklist for on-site compliance reviews that HUD staff conduct. We will continue to monitor HUD's progress in response to our recommendation.

Recommendation: The Director of HUD's Lead Office and the Assistant Secretary for PIH should collaborate to develop and document procedures to ensure that HUD staff take consistent and timely steps to address issues of public housing agency noncompliance with lead paint regulations. (Recommendation 5)

Agency: Department of Housing and Urban Development
Status: Open
Priority recommendation

Comments: As of November 2019, HUD officials told us procedures were in draft form and under internal review and were not expected to be finalized until spring 2020.

Recommendation: The Secretary of HUD should request authority from Congress to amend the inspection standard to identify lead paint hazards in the Housing Choice Voucher program as indicated by analysis of health effects for children, the impact on landlord participation in the program, and other relevant factors. (Recommendation 6)

Agency: Department of Housing and Urban Development
Status: Open
Priority recommendation

Comments: In response to this recommendation, HUD's fiscal year 2021 budget justification requested funds to test an alternative lead paint testing method in HUD's Housing Choice Voucher program. To fully implement our recommendation, HUD needs to continue to take steps to analyze potential effects of alternative lead paint testing methods, and use the results to inform its decisions about requesting new authority from Congress.

Recommendation: The Director of the Lead Office should develop performance goals and measures to cover the full range of HUD's lead efforts, including its efforts to ensure that housing units in its rental assistance programs are lead-safe. (Recommendation 7)

Agency: Department of Housing and Urban Development
Status: Open

Comments: As of November 2019, HUD officials told us they still were exploring whether current data systems could be used to count the number of lead-safe housing units in HUD's rental assistance programs. We will continue to monitor HUD's effort to implement this recommendation.

Recommendation: The Director of the Lead Office, in conjunction with PD&R, should finalize plans and develop a time frame for evaluating the effectiveness of the Lead Safe Housing and Lead Disclosure Rules, including an evaluation of the long-term cost effectiveness of the lead remediation methods required by the Lead Safe Housing Rule. (Recommendation 8)

Agency: Department of Housing and Urban Development
Status: Open

Comments: In November 2019, HUD officials told us they planned to use data from the forthcoming update to the American Healthy Homes Survey to better estimate the prevalence of lead paint hazards in federally assisted housing which would provide an indication of the effectiveness of the lead paint rules. However, officials told us the findings from the updated survey likely would not be available until summer 2020.

Recommendation: The Director of the Lead Office should complete statutory reporting requirements, including but not limited to its efforts to make housing lead-safe through its lead grant programs and rental-assistance programs, and make the report publicly available. (Recommendation 9)

Agency: Department of Housing and Urban Development
Status: Open

Comments: In November 2019, HUD officials told us they planned to issue a report to Congress on the agency's lead efforts in early 2020.