Improving Childhood Health: The Unrealized Potential of Medicaid’s EPSDT Program
September 8, 2021
Overview
In the United States, millions of children live in poverty and are at a much greater risk of experiencing adverse health outcomes compared to their contemporaries in higher income households. Low-income children of color are disproportionately at risk of having health problems including but not limited to, dental, hearing, speech, and vision problems; elevated lead blood levels; early childhood trauma; and asthma. Social risk factors such as the lack of access to healthy food, quality educational opportunities, greater environmental hazard exposures, and inadequate housing significantly increase the likelihood that a low-income child will be in poor health.
Early detection and treatment can avoid or minimize the effects of many childhood conditions.
To detect and treat the effects of many childhood conditions, in 1967 the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) service was added to the Medicaid program. The Medicaid Act requires participating states comply with the following requirements:
- All Medicaid-eligible children and youth under the age of 21 are eligible for EPSDT; and
- States must provide eligible children with periodic medical check-ups called “medical screens,” that include:
- a comprehensive health and developmental history;
- a comprehensive unclothed physical exam;
- immunizations;
- laboratory test when appropriate, including lead blood testing; and
- health education and anticipatory guidance
If all of these components are not offered at a visit, the visit cannot be reported by the state on the Form CMS-416, which measures the state’s attainment of participant and screening goals.
“The EPSDT participation and screening data are vital to decision makers in their assessment of the services provided to eligible children.” – Office of Inspector General, 1992
The National Health Law Program (NHeLP) developed both a chart book, Children’s Health Under Medicaid, and companion analysis comprised of Form CMS-416 data for Federal fiscal years 2015 – 2019 to highlight trend patterns and projections to help advocates identify areas in which states’ EPSDT performance and reporting need further scrutiny and improvement, as demonstrated in a recent Georgia Health News article testimonial.
Since its inception, the EPSDT program’s success in screening and treating eligible children has not met expectations.
The Medicaid Act established that each state provide at least 80 percent of EPSDT recipients with timely screens by fiscal year 1995. Unfortunately, states have remained far from reaching that goal. Of the 41.4 million children eligible for EPSDT in fiscal year 2019 only 20.7 million (approximately 50 percent) received at least one initial or periodic screen.
Millions of children are eligible for EPSDT, meaning it has the potential to significantly improve the overall health of children in the United States. Resources such as the chart book and its companion analysis are integral to ensuring states are fulfilling their legal responsibility to assure preventive care for the nation’s children.
“… the earlier a child is receiving care, the earlier they get treatment, the healthier they’re going to be in the long run.” – Daniel Young, NHeLP
For further information on EPSDT trend patterns and projections, see NHeLP’s Chidren’s Health Under Medicaid publication and the EPSDT Trends Fact Sheet 2015 – 2019.
This post was written by Zamir M. Brown, MPH, Health Policy Fellow, National Health Law Program. NHeLP is a partner organization of the Network for Public Health Law.
The Network for Public Health Law provides information and technical assistance on issues related to public health. The legal information and assistance provided in this post do not constitute legal advice or legal representation. For legal advice, readers should consult a lawyer in their state.
Support for the Network is provided by the Robert Wood Johnson Foundation (RWJF). The views expressed in this post do not represent the views of (and should not be attributed to) RWJF.