Preventive Health Coverage Under Medicaid Expansion
By Amit Chitre, CEO/Founder R3Communications
“An ounce of prevention is worth a pound of cure,” Benjamin Franklin famously quipped. The saying provides excellent guidance for individual health outcomes. But it can also be a good roadmap to improving population health and strengthening the health care system itself. Preventive health coverage has evolved under Medicaid expansion, and this evolution is making a notable impact on Medicaid and the people it serves.
Medicaid became law in 1965 to provide health coverage for low-income children, caretaker relatives, older adults, the blind and people with disabilities. President Lyndon B. Johnson signed the bill as an amendment to the Social Security Act as part of his vision for a "Great Society," which set goals to eliminate poverty and racial injustice.
Throughout the following five decades, Medicaid evolved to focus on preventive medicine as landmark legislation focused on keeping Medicaid populations healthy. For example:
- In 1967, the program established the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) The benefit provides preventive dental, mental health, developmental and specialty services for children under 21 enrolled in Medicaid.
- The Balanced Budget Act of 1997 established the State Children's Health Insurance Program (CHIP), which expanded coverage to many who were previously ineligible for Medicaid.
- A provision created in 2000 gave states the option to extend Medicaid coverage to uninsured women with breast or cervical cancer, which includes screenings that may identify a recurrent event.
- The Affordable Care Act (ACA) of 2010 further placed a focus on preventive health services for adults, such as cancer screenings, health education and chronic conditions.
But Medicaid was established as a federal-state joint initiative, and continues to operate in that capacity. While the federal government provides guardrails for states to navigate within, each state administers Medicaid differently. As a result, Medicaid coverage, including preventive health programs, vary from state to state. Arizona, for example, did not participate in Medicaid until 1982 so many of its Medicaid eligible residents did not receive preventive vision, hearing, dental or mental health screenings.
More recently, the ACA expanded Medicaid coverage to millions of uninsured adults who previously could not afford health coverage. But 19 states have elected not to expand coverage. This means two individuals of identical age, health profile, income and employment status could have significantly different levels of access to checkups, screenings and other preventive measures based on the state in which they live. Compounding the impact of that access over years and decades could result in a huge gap between those two individuals in overall health, health care expenses, quality of life and perhaps even life expectancy.
The difference in access to care is significant considering the population Medicaid serves. Studies show people living in poverty get sick more often, and have a shorter life expectancy, than the affluent. The rate of children diagnosed with asthma, AHDH or autism has grown more quickly among poor children than children from higher-income homes. Lower-income people also have a 50 percent higher risk of developing heart disease, the leading cause of death in the United States. In essence, poverty itself is a risk factor for poor health, and this health disparity among socio-economic classes makes access to preventive care even more important.
Medicaid expansion seems to have made a difference in improving health care access for lower-income people. Research shows states that have expanded Medicaid programs have experienced an increase in Medicaid enrollment. Studies also show larger increases in use of preventive services in expansion states compared to nonexpansion states, including services like dental visits, breast exams and mammograms. One JAMA Internal Medicine study compared outcomes in three states: Kentucky, which expanded its traditional Medicaid program; Arkansas, which implemented an alternative Medicaid expansion plan; and Texas, which did not expanded Medicaid. When compared with no expansion in Texas, the study found that Medicaid expansion in Arkansas and Kentucky was associated with a:
- 16 percent increase in residents' likelihood to have received a checkup in the last year.
- 12 percent increase in receiving regular care for a chronic condition.
- 6 percent increase in screening for diabetes.
- 6 percent decrease in the likelihood of emergency room visits.
Millions of residents who took advantage of Medicaid expansion are now watching to see how their benefits might change. As Congress debates plans to repeal and replace the ACA, it must consider how to manage the recently expanded Medicaid coverage. If Congress decides to eliminate or reduce federal funding for expanded coverage, states would be left choosing between difficult options: pay from their own funds to maintain coverage or drop the recent enrollees from the Medicaid program. States might also try to carve out a middle ground by reducing some of Medicaid’s preventive services or rolling back coverage to below poverty levels.
If early data have shown Medicaid expansion, and its preventive services, have improved key metrics of accessibility, affordability and utilization, we could logically expect a contraction of those services to result in the opposite. Regardless of how Medicaid evolves, policymakers would be wise to continue focusing on prevention. Without these services, poor populations will have fewer opportunities to break out of the cycle that destines them to poorer health outcomes.