Will current Medicaid enrollees receive less preventive care than expansion counterparts?

by Adrianna McIntyre

I’ve heard benefits under the reform’s Medicaid expansion criticized as offering patients “Medicaid lite“, a thinner version of the safety net program states already have in place, but a recent piece in Health Affairs by  Sara Wilensky and Elizabeth Gray (gated) suggests that it might be the other way around—at least when it comes to preventive services.

The Medicaid-lite critique goes something like this:

Under the ACA, states are permitted to provide a “benchmark” benefit to adults who are newly eligible for Medicaid. This is a different, and potentially more limited, package of covered services than what is covered for others on the program… 

Fortunately, some groups cannot be required to enroll in the limited benefit, including people with disabilities, those who are dually eligible for Medicaid and Medicare, medically frail and special needs populations, medically needy individuals, children in foster care, some institutionalized populations, and beneficiaries who qualify for long-term care.

Except the ACA actually guarantees coverage of more preventive services—the ones described here—for Medicaid expansion adults and exchange beneficiaries. That protection doesn’t extend to most adults currently eligible for the Medicaid program. Wilensky and Gray write:

Federal policy makers highlighted the importance of covering these preventive services by requiring most insurers to do so, yet coverage for existing adult Medicaid beneficiaries is left to state discretion. This disparity in coverage requirements raises the question of whether states already choose to cover these preventive services in their Medicaid programs. If they do not, existing Medicaid beneficiaries may not receive preventive services that are required to be provided to most other insured people.

According to the authors’ analysis, fewer than half of state Medicaid programs currently cover the following preventive services, all required under the ACA in expansion and exchange plans.

HA_Wilensky

Though beyond the scope of this paper, I’d be interested to learn whether currently observed health outcomes vary between states in a way that correlates to the provision of these services. The authors do note:

Access to preventive care is especially important for Medicaid enrollees, who are more likely than those who are privately insured to be in poor health, have a chronic condition, and have work limitations because of poor health. Compared with privately insured and uninsured people, Medicaid patients experience higher rates of many health conditions that are targeted by preventive services recommendations, such as hypertension, coronary heart disease, diabetes, and depression.

It would be convenient to dismiss this as a glitch or oversight, but it’s quite evidently not: the reform law includes  language to encourage—but not requirestates to cover these services for their existing Medicaid populations. Among the more alarming nuggets in the article is that most Medicaid officials were unaware of those incentives when the authors were collecting their data. Since then, a letter has been issued to program directors and the authors concede that higher-level state officials may have been aware of the provision. Still, it’s another not-especially-promising footnote on ACA implementation, and a quirk worth watching.

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Adrianna is a graduate student in public policy & public health at the University of Michigan. Follow her on Twitter @onceuponA.

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