Health Policy Analysis Using the Milstead Framework: Michigan Filter First Law and Childhood Lead Exposure (Example Paper)

Assignment: Health policy analysis using the Milstead framework

Analyze a health policy in two ways: (1) analyze the process of putting it into place using the Milstead framework (policy process) from Short (2026) and Milstead and Knestrick (1998); and (2) analyze its effect by finding and evaluating evidence. The focus should not be APRN scope of practice or access to care; consider how other determinants of health affect community health. Choose legislation passed in your state (or federal legislation and its impact on your state).

Suggested format:

1. Introduction: the diagnosis, its ICD-10 code and why we should care, using state-level data (no mention of the policy solution).
2. Law or policy name and agenda setting: players, events, stakeholders, advocates and how the bill became law.
3. Government response: what made the policy official, what the law does and the problem it solves.
4. Policy and program implementation, including funding sources.
5. Policy and program evaluation: process (formative) and outcome (summative) measures.
6. Summary of the evidence: clinical evidence, policy (utilization) evidence and evidence that the policy improves health outcomes; strength of the evidence.
7. Conclusion: whether the issue has been resolved, whether evidence supports the policy and next steps.

Original example for study purposes (about 1,500 words).

Protecting Michigan’s Children From Lead in Drinking Water: An Analysis of the Filter First Laws

Introduction

Lead exposure remains one of the most preventable threats to children’s health in Michigan. Lead is a neurotoxin with no known safe level in children’s blood; even low levels are associated with reduced IQ, attention problems, learning disabilities and behavioral difficulties that persist into adulthood, and young children absorb lead more readily than adults. Clinically, exposure is documented with ICD-10-CM code Z77.011 (contact with and suspected exposure to lead), and lead poisoning with T56.0X1A (toxic effect of lead and its compounds, accidental, initial encounter). Michigan has one of the highest rates of elevated childhood blood lead levels in the nation, and in 2021, the state had among the highest percentages of tested children with elevated levels (Ignaczak, 2025; Oosting, 2023). Testing has been low: fewer than 16% of Michigan children were tested in 2022 (Ignaczak, 2025), which means the true burden is likely underestimated. The 2014–2015 Flint water crisis showed how drinking water can drive exposure; after Flint switched its water source, the percentage of children with elevated blood lead levels nearly doubled, from 2.4% to 4.9% (Hanna-Attisha et al., 2016). Drinking water in schools and child care centers is a particular concern because children spend many hours there and older buildings may have lead pipes, solder or fixtures. Of the 114 Michigan schools and child care centers that voluntarily tested between 2020 and 2022, most found elevated lead levels (Oosting, 2023).

Agenda Setting: The Filter First Laws

The Flint water crisis was the focusing event that placed lead in drinking water on Michigan’s policy agenda. National media attention, research by Flint pediatricians and engineers, community activism and lawsuits created public pressure, and Michigan strengthened its Lead and Copper Rule in 2018 (Oosting, 2023). However, the rule focused on community water systems, not on the plumbing inside schools. Advocates, including the Natural Resources Defense Council (NRDC) and a coalition of public health, medical, learning disability, education and environmental organizations, worked for about four years to promote a “filter first” approach: proactively installing lead-reducing filters rather than waiting for testing to find a problem (Roper, 2023). Key legislative champions were Representatives Ranjeev Puri and Cynthia Neeley and Senator Sylvia Santana, who sponsored House Bills 4341 and 4342 and Senate Bill 88 (Roper, 2023). Stakeholders included school districts, child care providers, parents, pediatricians, environmental agencies and taxpayers concerned about costs. The bills passed with bipartisan support, a key strategy given divided interests, and Governor Gretchen Whitmer signed them into law on October 19, 2023 (Oosting, 2023).

Government Response

The government response was legislative. The Filter First laws, including the Clean Drinking Water Access Act for schools (Public Act 154 of 2023), require every school and licensed child care center to install filtered bottle-filling stations or point-of-use filters certified to remove lead on drinking and cooking water outlets, with at least one filtered station for every 100 children (Michigan Department of Environment, Great Lakes, and Energy [EGLE], 2025; Oosting, 2023). Facilities must develop drinking water management plans that identify consumptive fixtures and filter maintenance schedules and must test filtered water regularly (Oosting, 2023). The problem the law addresses is children’s exposure to lead in drinking water at places where they learn and are cared for, which directly relates to preventing elevated blood lead levels and the neurodevelopmental harms described above. The law shifts the approach from reactive testing to primary prevention.

Policy and Program Implementation

Implementation is led by EGLE for schools, with child care requirements tied to licensing. The state operationalized the law by issuing guidance on approved filters, creating templates for drinking water management plans and setting deadlines: October 2025 for child care centers and the end of the 2025–2026 school year for schools (EGLE, 2025). Schools must test filtered water annually and child care centers every two years, and when lead is detected, facilities must inspect filters, replace cartridges and retest (Southwest Michigan First, 2026). The law was funded: lawmakers set aside $50 million in 2022, and in December 2024, EGLE awarded $50 million in federal American Rescue Plan Act funds to 612 public, charter and nonpublic school districts and 122 child care centers for bottle-filling stations, faucet-mounted filters, pitchers and replacement cartridges (EGLE, 2025). A nonpartisan analysis estimated total costs of up to $65 million (Oosting, 2023), and ongoing costs for filter replacement and testing will fall on schools and child care providers, raising questions about long-term sustainability.

Policy and Program Evaluation

Evaluation should include both process and outcome measures. Process (formative) measures answer whether the policy was implemented as intended: the percentage of schools and child care centers with approved drinking water management plans; the percentage of consumptive fixtures with certified filters by each deadline; the percentage of facilities completing required testing on schedule; filter cartridge replacement compliance; and the amount and distribution of funding, including whether high-need districts received adequate support. Outcome (summative) measures answer whether the policy worked: the percentage of filtered water samples below 1 part per billion (ppb) of lead, the level recommended for schools by the American Academy of Pediatrics (Council on Environmental Health, 2016); trends in blood lead levels among Michigan children ages 1–5, using the state’s new universal testing data; and, over the long term, school readiness and academic outcomes. Because universal blood lead testing at 12 and 24 months became required in Michigan in 2025 (Michigan Department of Health and Human Services, 2025), the state now has a better baseline to evaluate whether childhood exposure declines.

Summary of the Evidence

The evidence for the Filter First approach is strongest at the clinical and technical levels and weakest at the population outcome level. Clinical evidence that reducing lead exposure prevents harm is strong: lead’s neurotoxicity is well established, and the Flint data show that drinking water contamination can measurably increase children’s blood lead levels (Hanna-Attisha et al., 2016). Evidence that the intervention works is also strong: in a field study at 345 Flint locations, certified point-of-use filters reduced lead to below 0.5 µg/L in more than 97% of filtered samples, even when unfiltered water contained very high lead levels (Bosscher et al., 2019). Evidence that the policy leads to more appropriate use of the intervention is emerging: implementation data show that hundreds of schools and child care centers received funding and installed filters by the deadlines (EGLE, 2025). However, there is not yet direct policy evidence that Filter First lowers children’s blood lead levels, because the law is new, children are exposed to lead from multiple sources (especially old paint and dust at home) and baseline testing was limited. The available evidence is largely observational and engineering-based rather than from controlled studies of health outcomes, so the overall evidence supports the policy’s mechanism but cannot yet confirm its population health impact.

Conclusion

In my view, the problem of lead in school and child care drinking water is on the path to resolution but is not yet fully resolved. The policy process has worked well so far: a focusing event and sustained advocacy produced bipartisan legislation, and funding enabled implementation on schedule. The evidence supports the policy’s logic, since filters reliably remove lead and reducing exposure protects children’s development. However, success will depend on long-term maintenance, sustainable funding for cartridges and testing and rigorous evaluation linking water quality data to children’s blood lead levels. Next steps should include dedicated recurring state funding, public reporting of filtered water test results by school, technical assistance for under-resourced districts and child care centers and an evaluation partnership with universities using universal testing data. Because drinking water is only one source of lead, Michigan should also continue investing in lead service line replacement and lead paint abatement in older housing to address this determinant of health comprehensively.

References

Bosscher, V., Lytle, D. A., Schock, M. R., Porter, A., & Del Toral, M. (2019). POU water filters effectively reduce lead in drinking water: A demonstration field study in Flint, Michigan. Journal of Environmental Science and Health, Part A, 54(5), 484–493. https://doi.org/10.1080/10934529.2019.1611141

Council on Environmental Health. (2016). Prevention of childhood lead toxicity. Pediatrics, 138(1), Article e20161493. https://doi.org/10.1542/peds.2016-1493

Hanna-Attisha, M., LaChance, J., Sadler, R. C., & Champney Schnepp, A. (2016). Elevated blood lead levels in children associated with the Flint drinking water crisis: A spatial analysis of risk and public health response. American Journal of Public Health, 106(2), 283–290. https://doi.org/10.2105/AJPH.2015.303003

Ignaczak, N. M. (2025, May 20). Michigan mandates universal lead testing for children under 6. Planet Detroit. https://planetdetroit.org/2025/05/michigan-law-child-lead-exposure/

Michigan Department of Environment, Great Lakes, and Energy. (2025, January 14). By the numbers: Filter First program to reduce children’s exposure to lead in drinking water. https://www.michigan.gov/egle/newsroom/mi-environment/2025/01/14/by-the-numbers

Michigan Department of Health and Human Services. (2025, May 5). Michigan blood lead testing rules finalized; physicians now required to order testing for children at ages 12 months and 24 months [Press release]. https://www.michigan.gov/mdhhs/inside-mdhhs/newsroom/2025/05/05/universal-testing

Milstead, J. A., & Knestrick, J. (1998). [Insert full reference from your course readings.]

Oosting, J. (2023, October 19). Michigan makes history, requires filtered water in all schools, daycares. Bridge Michigan. https://bridgemi.com/michigan-government/michigan-makes-history-requires-filtered-water-all-schools-daycares/

Roper, C. (2023). Michigan adopts Filter First protections for kids. Natural Resources Defense Council. https://www.nrdc.org/bio/cyndi-roper/michigan-adopts-filter-first-protections-kids

Short, N. M. (Ed.). (2026). Milstead’s health policy and politics: A nurse’s guide (8th ed.). Jones & Bartlett Learning.

Southwest Michigan First. (2026, July 28). What’s happening at Michigan’s school drinking fountains? A look at the Filter First law. https://www.southwestmichiganfirst.com/whats-happening-at-michigans-school-drinking-fountains-a-look-at-the-filter-first-law