Ensuring Equal Access for Medicaid Children

OBRA89: THE FIRST FOUR YEARS Since Medicaid began, the program has sought to provide equal access to medical care for the low-income beneficiaries it serves. The equal access regulation (42 C.F.R. 447.204) was included in the original set of Medicaid regulations promulgated in 1966. It was modified slightly in 1978, but remained largely without substantive policy impact until the enactment of the Omnibus Budget Reconciliation Act of 1989 (P.L. 101-239, OBRA89). OBRA89 was the capstone to a string of federal laws that began in 1984, which dramatically expanded Medicaid eligibility for children and pregnant women and transformed Medicaid from an in-kind, income maintenance program tied to public assistance to a public health insurance safety net now serving more than 50 million Americans, including more than one-fourth of the nation's children. (Kaiser Commission on Medicaid and the Uninsured, 2004). Through a three-pronged strategy, OBRA89 provided children and pregnant women with a special status among beneficiary groups in the Medicaid program. First, it dramatically broadened the mandated eligible age group from low-income pregnant women and children to age seven, to all poor children to age 18. But unlike predecessor legislation that established eligibility expansions through income and age standards only, the Congress went much further to ensure that these new beneficiaries would receive the mainstream care that it intended. It created requirements in two areas that historically had been the prerogative of the states--benefits and provider payment--changing the latter through a toughened equal access standard. The benefits revision centered on a requirement that states provide enhanced early and periodic screening, diagnosis, and treatment (EPSDT) services. The EPSDT program is the federal mandatory Medicaid service that requires states to provide children, to age 21, with a set of preventive care services defined in consultation with established medical and dental groups. This benefits revision specified more comprehensive health screening services and more important, required states to provide any treatment service needed to remediate a medical problem identified in an EPSDT screening. States were explicitly mandated to provide services to children even if they exceeded the amount, duration, and scope of care identified in the state plan and were not provided to adults. Previously these "discretionary services" were optional. With respect to provider reimbursement, OBRA89 elevated the equal access requirements by shifting them from regulation to codified legislation. It also toughened the states' performance standards by requiring provider payments "sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area" (OBRA89, Section 6402). The notion of a geographic area baseline, with which Medicaid access to care would be compared and to which states would be held accountable, was entirely new. It also instituted comprehensive state reporting requirements to the Secretary of Health and Human Services (HHS) on the participation rates of obstetric and pediatric providers and payment rates for a long list of commonly provided pediatric and obstetric care services. The selection of only pediatric and OB services, as opposed to other possible groupings, such as all primary care or all federally mandated services, and its linkage to children's eligibility and benefits enhancements in the same legislation underscored the Congressional intent to ensure equal access to care specifically for children and pregnant women. These unprecedented legislative actions sent a clear message to the states that children and pregnant women must be furnished medically necessary care and created in the view of many, a special entitlement accorded to no other Medicaid-eligible subpopulations. …