Why We Care About Medicaid “EPSDT” Benefits
and So Should You

While threats to the Affordable Care Act (ACA) may seem the most imminent in our current political landscape, Medicaid is also under attack. Congress and the new administration are discussing deep cuts and changes to the Medicaid program, through Medicaid block grants or per capita program caps. The new administration recently said they will be proposing block grants. 

Medicaid block grants result in funding cuts and fewer people receiving coverage. Utah has long been recognized as a leader in health care innovation, but our ability to innovate will be severely impaired if we experience cuts to our foundational health care safety-net system through block grants. Medicaid is the cornerstone to children’s health coverage in Utah.

In a recent letter to Congress on January 13th, the Governor and state officials weighed in on a number of health reform proposals, including Medicaid. We saw many areas for concern in our state leaders’ letter; one brief recommendation in particular jumped out at us, because it would have significant and long-lasting consequences for children and families:

“Reevaluate the EPDST (Early Period Screening, Diagnosis and Treatment) benefit for children. EPDST requires states to provide comprehensive and preventative health services for Medicaid beneficiaries under the age of 21 with few limitations.
Consider limiting benefits to what is available in the private market. Currently, children on Medicaid have more access to services and benefits than children who are covered under good commercial plans.”

So, what is EPSDT?

Early, Periodic Screenings, Diagnosis & Treatment

The EPSDT benefit, known in Utah as “CHEC” or Children’s Health Evaluation and Care, is one of the hallmarks of the Medicaid program. The Medicaid Act currently requires states to provide children with a comprehensive scope of services. For decades, EPSDT has allowed providers to catch potential health problems early, when they are easiest to treat and children stand the best chance of developing to their fullest potential. Covered EPSDT services include basic preventative care, such as dental and vision services, plus services needed to address acute, long-term, and disabling conditions, such as physical, speech and behavioral health therapies and in-home nursing. The EPSDT benefit is considered the gold standard for children’s pediatric benefits. It helps doctors determine the best level of care for their patient.

EPSDT has helped millions of children, especially children with special health care needs, receive the level of the care they need. In fact, many families in the private insurance market will turn to Medicaid coverage for their children with special health care needs-- because they cannot afford such comprehensive benefits in their “good” commercial plan.

We Need to Protect EPSDT

Medicaid is the cornerstone for children’s health coverage in our state, and serves over 20% of our most vulnerable families. If we roll-back the EPSDT benefit, we will see a surge of parents no longer able to afford care, particularly for children with special health care needs.
EPSDT protects families; it assures families that they can receive a minimum level of coverage and have access to services that meet prevailing standards of care. For many higher-income families, Medicaid may seem unconnected to their day-to-day lives. But one of the core tenets of our health care safety-net is that it is there for families when they need it.

There are many improvements needed to our Medicaid program. But the EPSDT benefit package is not one of them. So why fix what isn’t broken? Instead, for example, Medicaid mental and behavioral health services should be better integrated and aligned with physical health benefits.
Instead of trying to raise health care standards for all kids, our state and federal leaders are instead looking to dilute standards. It is perverse logic to limit progress and roll-back gains, in order to achieve equality. Instead we should advance the progress made so all children can achieve affordable, comprehensive coverage.

We urge our state and federal leaders:

Do not limit benefits for children and weaken our existing standards.
Build on the progress we have made.
Strengthen coverage and care for all Utah children.

For 30 years now, Voices for Utah Children has called on our state, federal and local leaders to put children’s needs first. But the work is not done. The children of 30 years ago now have children of their own. Too many of these children are growing up in poverty, without access to healthcare or quality educational opportunities.

How can you be involved?

Make a tax-deductible donation to Voices for Utah Children—or join our Network with a monthly donation of $20 or more.  Network membership includes complimentary admission to Network events with food, socializing, and opportunity to meet child advocacy experts. And don't forget to join our listserv to stay informed!

We look forward to the future of Voices for Utah Children and we hope you will be a part of our next 30 years.

Special thanks to American Express, our "Making a Difference All Year Long" sponsor. 

Changes to Medicaid’s financing structure through a block grant or per capita cap would create large shortfalls in state funding. These would inevitably lead to limits placed on the program, such as a reduction in benefits or fewer children covered. The impact of these cuts would be even greater when utilization or enrollment goes up. For example, Utah would not be able to keep up with Medicaid demand during a recession, when many more children become newly eligible for and enroll in Medicaid. During the last recession, Medicaid added 30,000 enrollees in one year, a growth rate significantly higher than previous years. Under a block grant or per capita cap structure, the state would not be able to meet this sudden demand.

The charts below illustrate the Utah budget impact of the most recent House of Representatives block granting or per capita cap scenario if it had gone into effect a decade ago. The scenario is based on House Speaker Ryan’s federal budget proposal for FY2017. Under the proposal, Utah could expect to see a 25% cut to its federal Medicaid funding by the end of the first decade, because the proposal limited increases in federal Medicaid funding to the general consumer inflation rate rather than the medical cost inflation rate, which is higher (even for Medicaid, which has a lower inflation rate than private insurance). Thus, the scenarios below show federal Medicaid funding to Utah increasing annually by about 2% rather than the actual average increase of over 5%.

Since the Ryan proposal did not specify a state match or Maintenance of Effort (MOE) requirement, we present a worst-case scenario where Utah’s state Medicaid contribution remains flat at the FY2007 level and a best-case scenario where Utah’s state Medicaid contribution increases by 60% over the last decade (as it actually did in nominal terms, not adjusted for inflation).*

*Based on information available from Utah Medicaid Annual Reports. For additional information on Speaker Ryan’s proposals see the Congressional Budget Office report, “The Long-Term Budgetary Impact of Paths for Federal Revenues and Spending Specified by Chairman Ryan,” March 2012, .

For 30 years now, Voices for Utah Children has called on our state, federal and local leaders to put children’s needs first. But the work is not done. The children of 30 years ago now have children of their own. Too many of these children are growing up in poverty, without access to healthcare or quality educational opportunities.

How can you be involved?

Make a tax-deductible donation to Voices for Utah Children—or join our Network with a monthly donation of $20 or more.  Network membership includes complimentary admission to Network events with food, socializing, and opportunity to meet child advocacy experts. And don't forget to join our listserv to stay informed!

We look forward to the future of Voices for Utah Children and we hope you will be a part of our next 30 years.

Special thanks to American Express, our "Making a Difference All Year Long" sponsor.