One Lesson of Healthcare Push: EPSDT is Vulnerable

As every American with an electronic device knows, the American Health Care Act (AHCA) – the Republican bill to repeal and replace the Affordable Care Act (ACA) – was pulled off the table Friday just before a vote was to take place, as House leaders came to grips with the fact that they did not have the votes to pass it.

But child welfare advocates should take note of something that happened in the days leading up to the vote that never was. Early and Periodic Screening, Diagnostic and Treatment (EPSDT), a Medicaid provision that guarantees assistance to low-income children, all of a sudden became optional.

In short, the idea behind EPSDT is to identify and deal with potential health issues – which include mental health, preventative health, dental health, and other special health services – at an early age as to avoid possible lifelong impact.

States are obligated by federal law to provide EPSDT to all of their Medicaid-eligible children. Studies from the 1990s and 2000s suggested the benefit was underused, and a 2008 policy paper argued that EPSDT was badly in need of updated guidelines after 40 years.

As President Trump and House leaders horse-traded to convert the most conservative Republicans into Yay votes, an amendment on March 20 was introduced. AHCA was already shifting Medicaid to a per-capita structure that would have lowered spending over time, and the amendments offered states the option to take Medicaid as a more flexible block grant.

In this block grant structure, the definition of “medical assistance” that enumerates EPSDT as a mandate would have gone away. Here is how the Kaiser Family Foundation described the new rules of the road for block grant states (with emphasis added):

States must provide hospital care, surgical care and treatment, medical care and treatment, obstetrical and prenatal care and treatment, prescribed drugs, medicines, and prosthetic devices, other medical supplies and services, and for children under 18, health care (but not Early, Periodic, Screening, Diagnosis and Treatment services).

The dismissal of EPSDT was, at least to Youth Services Insider, a bit surprising. The plan with AHCA was to constrain Medicaid to women, children and the disabled. That notion is hardly compatible with erasing the most specific guarantees of care to children.

Since every child in foster care is eligible for Medicaid, they are all in turn eligible for the full breadth of EPSDT services. AHCA kept a guarantee of Medicaid eligibility for aging foster youth through age 26, but the removal of EPSDT guarantees for younger foster youth could have been a significant blow.

It is unclear at this point if a new health care reform will be mounted in the near future, or if the GOP leadership and President Trump will move to new issues. Sen. Tom Cotton (R-Ark.), in an interview on CBS’ Face the Nation, suggested that the September deadline to reauthorize the Children’s Health Insurance Program might offer an opportunity to push some conservative changes.

Whenever health care reform comes up again, one thing is clear: the Medicaid guarantees to children are fair game in the battle to lower federal spending. EPSDT is not a sacred cow.

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John Kelly, Editor in Chief, The Chronicle of Social Change
About John Kelly, Editor in Chief, The Chronicle of Social Change 1213 Articles
John Kelly is editor-in-chief of The Chronicle of Social Change. Reach him at