Marilou Yingling has run York's home lead testing and enforcement program for 28 years.
She used to have a seven-person team that would travel around the city offering to test homes and children for lead exposure.
These days, she's on her own. She has a backlog of homes that need to be tested. When she does conduct a home inspection, her department often doesn't get reimbursed for the service.
"I've had fifteen referrals since the beginning of the year," Yingling said. "I think I've been reimbursed for three."
There's a reason for that, she said. A state policy change has cut off the funding source that used to pay for lead inspections across Pennsylvania.
Under the old system, lead inspectors would bill the state $350 for each home inspection. That money would go back into local health department budgets to pay for things like radioactive elements in lead testing devices and other supplies, such as lead testing kits, that would often go to families, Yingling said.
Under a new system, which began this year, the state requires Medicaid insurers to pay for lead testing. That means lead inspectors need to set up contracts with each of the Medicaid insurers.
That's become a problem for a number of lead inspectors around the state, Yingling said. In her case, only one of the five Medicaid insurers in her area, Gateway, has agreed to set up a contract with her.
She doesn't know why the others won't set up contracts with her, but said it's making it harder for her to do her job.
She's not an isolated case.
In Harrisburg, Joyce Ravinskas runs UPMC Pinnacle's lead testing program. Ravinskas and one other inspector do home lead testing for a 13-county region.
"The Department of Human Services no longer pays for the [environmental lead inspections] we do," she said. Her team is still conducting inspections for now, she said. But without funding, it's uncertain what will happen.
This new problem follows years of state and federal funding cuts for lead programs, Ravinskas said.
She used to run a staff of 15, with field offices in Wilkes-Barre and Reading and a $3.3 million, three-year grant.
She lost that funding in 2016. That led to the program shuttering the Wilkes-Barre and Reading offices, cutting staff and shrinking its coverage area.
Though funding for lead testing has gone away, the problem hasn't. In 2017, about 7,000 children on Medicaid had blood lead levels of 5 micrograms per deciliter or higher, according to Sally Kozak, Deputy Secretary for the stage Department of Human Services Office of Medical Assistance Program.
The Department of Health only requires a doctor to schedule a lead home inspection when a child has a level of 10 micrograms per deciliter or higher, Kozak said.
However, in 2012 the Centers for Disease Control changed its guidance on lead, stating that there is no safe level of lead in the blood, and that levels below 10 micrograms per deciliter still do irreversible harm to children.
Under the old system, many inspectors used a state database to track all blood lead cases and would still reach out to families whose children were below the 10 micrograms per deciliter threshold, Yingling said.
Now, many of those same inspectors are being pushed out of the job, while Medicaid insurers opt instead to contract with one private company.
Medicaid insurers Gateway, AmeriHealth Caritas and UPMC for You confirmed in emailed statements that their main contractor across the state is a company called Accredited Environmental Technologies. Aetna and United declined to comment.
The company, with offices in Delaware County and Fayette County, is described on its website as a team of "environmental consultants specializing in real estate due diligence, health and safety engineering, inspections, sampling, risk assessments and laboratory testing."
AET vice president Eric Sutherland and other company executives did not respond to multiple requests for comment over a two-week period.
At the state, Kozak said Pennsylvania's Medicaid insurers are free to contract with whatever lead inspectors they choose, as long as they are properly credentialed.
"The managed care organizations have to have an adequate network to perform the work, so they contract with whatever number of providers they need to provide the service," she said.
The state is responsible for making sure the Medicaid insurers follow their agreements with the state, she said, and has systems in place to do so. The state's compliance department reviews records provided by the insurers to determine that they're meeting the regulations.
Kozak said the insurers may prefer Accredited Environmental Technologies because it offered to do the work at a lower rate.
"I think from a contracting perspective the managed care organizations try to come to an agreement with those... willing to negotiate with them," she said.
Department of Human Services spokesman Colin Day said families on Medicaid will still get their homes inspected when needed. However, in York, Yingling said she worries that children who have blood lead levels between 5 and 9 micrograms per deciliter will "fall through the cracks."
Many inspectors go above and beyond the bare minimum of home inspections required by the state, she said. She and others often call or mail lead safety information to families whose children show up in the lead database with lower levels, which still show that the child is being exposed to lead.
Yingling said, if she had the ability to make it happen, every child would be tested for lead exposure. That's something that 10 other states, as well as the District of Columbia, already do.
However in Pennsylvania only children on Medicaid have to get tested, and not as often as she thinks they should.
She noted that, from her past work, she could expect about 20 percent of all children living in the city to end up having lead in their blood.
"About 1,000 children are being tested by their doctors (in York), and about 20 percent are testing positive," she said. "It's bigger than a lot of other areas, including what they saw in Flint with the water crisis."