Providing Access to Preventative Health Care: Child Health and EPSDT

Former South African President Nelson Mandela stated “there can be no keener revelation of a society’s soul than the way it treats its children.” As a nation, children are our greatest resource and providing them with health coverage is critical for child development. If we want children to grow up to be healthy, well-adjusted and productive citizens, then we must take care of their basic needs. No other federal policy has done more to advance the health and well-being of low-income children than Medicaid (also known as Title XIX). For 45 years, Medicaid has provided comprehensive and preventive health care to U.S. low-income children through a special benefits program known as Early and Periodic Screening, Diagnosis and Treatment (EPSDT). EPSDT is the child health component of Medicaid. It provides pediatric services to low-income children under age 21 who qualify for Medicaid. Today, one in three children under age six qualify for Medicaid. Enacted by the Social Security Act Amendments of 1967 (Section 302 (a) P.L. 90-248), the program was originally created to address the high rejection rates of military draftees, who suffered from untreated and preventable childhood illnesses (Rowland, Diane. Medicaid at Forty. Health Care Financing Review. Winter 2005-2006 Volume 27 (2): 63-77). Since this time EPSDT has provided comprehensive health coverage to low-income children. Approximately 29 million children receive Medicaid today.

Program

The goal of the EPSDT program is to detect health problems early and treat acute and chronic health conditions. The program has two operational components: 1) “assuring the availability and accessibility of required health care resources, and 2) helping Medicaid recipients and their parents or guardians effectively use them.” Screening services are provided in four areas: 1) dental, 2) vision, 3) hearing, and 4) medical. Medical screenings include a comprehensive physical exam, comprehensive developmental history, appropriate immunizations, laboratory tests and health education as needed (U.S. DHHS, CMS; Kaiser Family Foundation, October 2005). In terms of periodicity schedules, states are given flexibility in setting the frequency and timing of screens, which can create variation across states. Once a medical condition has been diagnosed Medicaid must pay for the necessary medical treatment to correct the problem even if the state Medicaid program does not cover the procedure. This requirement is significant because it makes Medicaid services for children far more comprehensive than for adults since adult services can be restricted and denied. Moreover, the EPSDT program provides more comprehensive services for children with disabilities than private insurance plans (Kaiser Family Foundation, October 2005), rendering it a highly valuable program for low-income families.

Federal Legislation

Federal EPSDT policy has evolved over time. Due to slow adoption by states, in 1989, EPSDT became a statutory requirement mandating all states participating in Medicaid to provide services to children and youth up to age 21 with annual incomes less than 133 percent below poverty (Rowland 2005). The required expansion of services was linked with reporting requirements. Beginning in 1990, states were required to submit an annual report (Form 416) to the U.S. Department of Health and Human Services. In addition, an 80 percent participation rate for EPSDT was set with a target date of 1995. The program was further expanded by the Omnibus Budget Reconciliation Act of 1990 (P.L. 101-508), which included coverage of children ages 6 to 18 with annual incomes less than 100 percent of the federal poverty level (U.S. GAO, 2001). In 1997, the Medicaid program and the EPSDT benefit shifted to managed care plans through the State Children’s Health Insurance Program (SCHIP), which was created by the Balanced Budget Act of 1997 (P.L.105-33). State Medicaid programs viewed managed care as a way to reduce costs and expand services (Silberman, Poley, James, Slifkin, 2002; Coughlin, Zuckerman, Wallin, and Holahan, 1999). However, there is concern that the incremental strides made in Medicaid’s EPSDT program are being weakened by the Deficit Reduction Act of 2006 (P.L. 109-171). The Act gives states more flexibility in designing the benefit package to Medicaid recipients, allows states to charge fees and premiums for children’s doctor visits, and requires documentation of citizenship, which could all negatively impact Medicaid participation (National Health Law Program). Today the EPSDT program provides services to approximately one in four children in the U.S. (Kaiser Family Foundation, October 2005).

Utilization and Access

Given the pivotal role that health care plays in positive health outcomes for children, the significance and impact of the EPSDT program cannot be overstated. However, program access and utilization have been problematic. Despite EPSDT’s comprehensive benefits and federal requirement that state’s inform all eligible Medicaid recipients under 21 about EPSDT (Section 1902(a)(43) of the Act), the program is not fully utilized by eligible children. Obstacles to utilization are identified as either program related or beneficiary related. The two main program-related obstacles are low provider participation in Medicaid and barriers in the eligibility process. Beneficiary related issues contain a host of issues. Low participation among pediatricians, dentists, and mental health providers is caused by low reimbursement, excessive paperwork and capitation (Berman, Dolins, Tang, and Yudkowsky, 2002; McManus, Flint and Kelly, 1991; Physician Payment Review Commission, 1991), making access to care difficult for Medicaid beneficiaries. In addition, Medicaid parents find Medicaid eligibility a complex process. A focus group session conducted by the Kaiser Family Foundation found that low-income parents do not understand the Medicaid and SCHIP eligibility process. Specifically, the paper work is burdensome and complicated, creating barriers to participation for eligible beneficiaries. When beneficiaries do become enrolled in Medicaid they face a host of obstacles, which include: unreliable transportation, inflexible work hours, language barriers, lack of continuity in primary care services, and geographic misdistribution of existing network providers (Thompson, et al 2003. Quality of Care for Children in Commercial and Medicaid Managed Care. JAMA September 17, 2003 Vol. 290, No. 11 PP. 1486-93. These factors are exacerbated by the fact that children enrolled in Medicaid who receive services provided by managed care organizations (MCOs) often receive a lower quality of care than their private enrolled counterparts in the same MCO (Ibid.).

Conclusion

Medicaid and EPSDT is a critical program for low-income children that provides preventative health care services and as such, offers long term cost savings. The program has a strong success record. However, despite the comprehensive services and Medicaid expansion approximately 8.9 percent of children in the U.S. remain uninsured. If we value our children and their health we need to increase enrollment and eliminate barriers to access and utilization. Collaboration between Title V Maternal Child Health programs and EPSDT is a significant and positive step to addressing these barriers, but more work needs to be done. In the words of Lillian Katz, “The good life for our own children can be secured only if a good life is also secured for all people’s children.”