EPSDT: The little known acronym that helped millions of children

By Emma Sandoe

This year marks the fiftieth anniversary of the passage of the legislation that created the Early Periodic Screening, Diagnostic, and Treatment (EPSDT) program. The program requires states to provide screening and treatment to Medicaid eligible low-income children under the age of 21. In 2014 an estimated 40 million American children, or nearly one in every two kids, were eligible for this program. The Republican Obamacare repeal bills, the American Health Care Act (AHCA) and Better Care Reconciliation Act (BCRA) gives states the option to end this program for certain kids. EPSDT has improved the lives of millions of children and families in the Medicaid program over the last 50 years and has incidentally improved care for many millions more Americans.

As part of the first bill that made changes to Medicaid, this policy would become one of the most significant developments in the history the public health insurance program. Medicare and Medicaid were passed and signed into law in July of 1965 under the Medicare Act of 1965. A year later, the Medicaid program began to be implemented in states that took up the option. By the end of 1967, 38 states had opened their Medicaid programs to enrollment and begun providing services to low-income single-parent families and elderly and disabled individuals. Despite these coverage gains and medical treatment, many low and moderate-income children in two parent households lacked access to medical care. EPSDT was the first of many significant Medicaid coverage expansions to children. What was unforeseen at the time was the way that the benefits of EPSDT have been felt across the health care system and broader population.

The Social Security Amendments of 1967 included ten policy changes to the Social Security program and eight major modifications to Medicaid and other programs run by the welfare agency Aid for Dependent Families and Children (ADFC). The most prominent debate at the time was over the newly created Medicare program that was already seeing high expenditures in the infancy of the program. For example, the first recommendation made by the government agency charged with running Medicare was to cover prescription drugs. As part of this bill, the Johnson administration had proposed extending Medicare coverage to people with disabilities and the restriction of certain payments to states for adult care services. Despite nearly a year of debate, the EPSDT changes to Medicaid were little discussed. This is consistent with the debate over Medicare and Medicaid in Congress only two years earlier and draws comparisons to the current reform debate today. Despite the large role that Medicaid plays in coverage and financing of health care, it often is secondary in the policy debate.

EPSDT requires that states screen and treat children for childhood diseases, regardless of whether the services required are covered by the state’s Medicaid program. This caveat has played a significant role in ensuring the Medicaid program responds to the needs of patients and that coverage modernizes as the health care practice develops.

Medicaid is the primary payer of long-term service and supports- the “non-medical” services required to sustain a person’s ability to live in the community. These can range from nursing facility care to aid with eating and preparing meals. At its inception, Medicaid did not provide many options for long-term care services outside of a nursing facility. Through children becoming eligible for treatment for long-term care services because of diagnoses made through EPSDT the need to treat children in the home, rather than a nursing facility became evident. At this time, conditions in nursing facilities had fewer regulations and they were, and many remain, unpleasant places for children to spend their childhood. Therefore, states began forging relationships with home and community-based entities that would continue as policy changes were made to Medicaid that expanded home care to disabled adults and seniors. Today, spending on home and community-based services have surpassed spending on nursing facilities.

This benefit of long-term care services provided in the home and community is enjoyed by millions of adults and seniors in both low and middle class families and it would not have been made possible without first covering children through EPSDT. Children’s health services are inexpensive and the EPSDT benefit is low cost in comparison to many other health services. Even those with the most rare conditions only accounted for approximately 3 percent of Medicaid spending in 2005. The services that are provided under the EPSDT benefit can help keep children healthy for the rest of their lives. For example, EPSDT covers immunizations, lead screenings, and developmental examinations. So in terms of bang for your buck, this is one of the most cost effective programs we provide to keep our nation healthy.

Under the AHCA and BCRA, states can elect to block grant their Medicaid services. Under these proposals, the mandatory coverage of EPSDT is no longer required. While many states will opt for the per-capita cap option because it offers more federal financing, some states may elect to take the block grant option that offers fewer federal mandates. These states would no longer be required to test and treat children and the requirement to cover all services regardless of whether they are offered to other Medicaid patients would be eliminated.

Already only 60 percent of children eligible for EPSDT services receive testing from their state. Many states provide services to fewer than one in ten older children and young adults. There has been significant improvements to the coverage of children and adherence to the EPSDT requirements over the last 50 years. The AHCA and BCRA could reverse some of this progress and increase costs for everyone as fewer children receive vital vaccines and other health services and have worse health as adults.

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