Fifty years ago, after learning that half the young men drafted for the Vietnam War failed baseline health exams, the federal government instituted Medicaid’s comprehensive, pediatrician-recommended benefit standard for children known as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT).

The federal benefit standard in Medicaid ensures that low-income and vulnerable children receive the health care services they need to grow and thrive. But this standard is at risk.

Proposed cuts to Medicaid and CHIP funding could make EPSDT unaffordable to states. In turn, proposed changes to federal policy, including legislative and administrative action, could potentially give states the option to eliminate the standard except as it applies to children with disabilities.

In our new EPSDT brief, we explain why such a move would be shortsighted as children with serious disabilities make up only a small share of children enrolled in Medicaid and the Children’s Health Insurance Program (CHIP) who benefit from EPSDT.

Key Findings include:

• Our country’s lowest-income and most vulnerable children rely on Medicaid, including 4 in every 5 low-income children and nearly half of newborns, children under the age of 6, and children with special health care needs. These children have higher health care needs and live in families who cannot afford the cost of services needed if Medicaid did not encompass the full scope of EPSDT services.
• EPSDT is uniquely designed to meet these higher health care needs and to maximize a child’s potential by addressing developmental delays and health conditions that affect school performance and success in life.
• Restructuring Medicaid financing or cutting funding for Medicaid or CHIP would shift costs to states and likely result in cuts to eligibility or benefits for children, including the potential elimination of EPSDT standards. Without EPSDT’s child-focused, pediatrician-recommended benefits, Medicaid coverage could fall short of meeting the health care needs of millions of children, particularly those with special health care needs.

Federal policy proposals to make EPSDT optional seem to recognize its importance to children with disabilities. But children who qualify for Medicaid based on disability status represent a very small share of the 36 million children currently enrolled in Medicaid or CHIP.

Generally speaking, in order for children to qualify for Medicaid based on disability, children must qualify for Supplemental Security Income (SSI) although states serve a relatively small number of higher-income children with disabilities through Katie Beckett or home- and community-based waiver programs.

In 2012, there were 1.3 million children receiving SSI, yet in the same year 6.3 million children on Medicaid were reported to have special health care needs. Clearly, these children, as well as those who suffer an acute developmental issue that can be remedied, would be at risk of not receiving the benefits they need to succeed in school and life if EPSDT standards are weakened or eliminated.

EPSDT requires that states consult with medical and dental organizations in establishing intervals for screenings and tests, and in determining if an evidence-based service or treatment is medically necessary.

Waiving the federal Medicaid benefit standard for children or making EPSDT optional for states means that politicians, not pediatricians, get to determine what’s best for children’s growth and development. This contradicts what HHS Secretary Tom Price has said repeatedly about allowing doctors not government to make decisions about health care.

There were clear and compelling reasons why EPSDT was introduced to improve the capacity of the health care system to identify, assess, and treat children with early signs of physical and mental health conditions that may affect growth and development.

In fact, EPSDT was initiated following health research from early Head Start demonstrations and reports on the poor health of young men drafted for the Vietnam War. EPSDT remains as relevant today as it did 50 years ago, and limiting this critical benefit would be shortsighted.