National Surveys Show That Certain Health Conditions Are Prevalent among Children and Adults in Medicaid, and Receipt of Recommended Preventive Services Varies Widely

National survey data suggest that children in Medicaid under age 21 are at  risk of certain health conditions, particularly obesity, that can be identified  or managed by preventive services, and many are not receiving well-child  check ups. 1). Among Medicaid children aged 8 through  20 years, an estimated 4 percent had high blood pressure. Among Medicaid  children aged 6 through 20 years, an estimated 10 percent had high  cholesterol. Among Medicaid Children, Almost Half Did Not Receive a Well-Child Check Up during a 2-Year Period

MEPS data from 2003 through 2006 suggest that many children in Medicaid  do not regularly receive well-child check ups. An  estimated 57 percent of Medicaid adults had obesity, diabetes, high  cholesterol, high blood pressure, or a combination of these conditions. 3). Estimated rates of high blood pressure and high  cholesterol were similar between both health insurance groups (see fig. The NHANES interview data also suggest that a large proportion of adults  in Medicaid found to have these health conditions may not have been  aware of them prior to participation in the NHANES examination. 4). Medicaid Adults’ Receipt of Recommended Preventive Services Varied Widely by Service

MEPS data suggest that Medicaid adults’ receipt of recommended  preventive services varied widely by service. Most  states also reported undertaking multiple initiatives since 2004 to promote  preventive services. When asked the reasons why they were not conducting more monitoring  of children’s utilization of preventive services in Medicaid (beyond  federally required monitoring through the CMS 416), the top two reasons  states chose were “administrative burden” and “technology challenges.”
In addition to monitoring specific preventive services, about two-thirds of  state Medicaid programs reported that the state had established its own  target goals or benchmarks for children’s utilization of preventive services,  in addition to the CMS goal that each state provide EPSDT well-child  check ups to at least 80 percent of Medicaid children in a state who should  receive one, based on the state’s periodicity schedule. For Adults, Most State Medicaid Programs Reported Covering Some but Not All Recommended Preventive Services

Most state Medicaid programs reported that they choose to cover some  but not all of the preventive services we asked about on our survey. Of the  eight recommended services we asked about, the services that were most  commonly reported as covered for adults were cervical cancer screenings  and mammograms, which were covered by 49 and 48 states, respectively. Four additional preventive services were reported as covered for adults by  three-quarters or more of the 51 states. Of those  eight states, six had not had their EPSDT programs reviewed by CMS  between April 2001 and June 2009. CMS oversight of preventive services for children in Medicaid also  includes providing policy guidance to state Medicaid programs, such as  through its State Medicaid Manual and other guidance; for example, CMS  officials reported that they intend to draft guidance for states on coverage  of obesity services as part of EPSDT services, but as of the time of our  review had not done so. A 2006 study raised concerns that Medicaid  providers may not be aware to what extent obesity services were covered  or reimbursed under EPSDT, and that states’ provider manuals did not  often explain this coverage. For Adults in Medicaid, CMS Has Recognized the Value of Preventive Services and Provided Oversight by Issuing Some Related Guidance for State Medicaid Programs

Unlike CMS’s oversight of children’s EPSDT services, CMS is not required  to collect utilization data from states on adults’ receipt of services and— according to officials—does not conduct program reviews as it does for  EPSDT services for children in Medicaid. Although Medicaid children generally are entitled to coverage of  EPSDT services that may identify and address health conditions such as  obesity, both national survey data and states’ 416 reports to CMS suggest  that children’s receipt of EPSDT services is well below national goals. State-specific reviews of  EPSDT programs have helped identify needed improvements but too few  have been done. However, gaps in provision of services remain. For this study, we examined data from 1999 through  2006 on children aged 2 through 20 and adults aged 21 through 64. Blood Pressure Test. It included  questions on the coverage of preventive services for adults, the methods  used for oversight of preventive services for children and adults, including  monitoring of utilization of specific services, utilization goals, including  whether or not goals were being met, state promotion efforts and specific  initiatives aimed at preventive services, and the federal support provided  to state Medicaid programs for the provision of preventive services.
Why GAO Did This Study

Medicaid, a federal-state program that finances health care for certain low-income populations, can play a critical role in the provision of preventive services, which help prevent, diagnose, and manage health conditions. GAO examined available data to assess (1) the extent to which Medicaid children and adults have certain health conditions and receive certain preventive services, (2) for Medicaid children, state monitoring and promotion of the provision of preventive services, (3) for Medicaid adults, state coverage of preventive services, and (4) federal oversight by the Centers for Medicare & Medicaid Services (CMS). GAO analyzed data from nationally representative surveys: the National Health and Nutrition Examination Survey (NHANES), which includes physical examinations of participants, and the Medical Expenditure Panel Survey (MEPS). GAO also surveyed state Medicaid directors and interviewed federal officials.

What GAO Found

Nationally representative data suggest that a large proportion of children and adults in Medicaid have certain health conditions, particularly obesity, that can be identified or managed by preventive services, and adults' receipt of preventive services varies widely. For Medicaid children, NHANES data from 1999 through 2006 suggest that 18 percent of children aged 2 through 20 were obese, 4 percent of children aged 8 through 20 had high blood pressure, and 10 percent of children aged 6 through 20 had high cholesterol. Furthermore, MEPS data from 2003 through 2006 suggest that many Medicaid children were not receiving well-child check ups. For Medicaid adults aged 21 through 64, NHANES data suggest that more than half were obese or had diabetes, high cholesterol, high blood pressure, or a combination. MEPS data suggest that receipt of preventive services varied widely by service: receipt of some services, such as blood pressure tests, was high, but receipt of several other services was low. MEPS data also suggest that a lower percentage of Medicaid adults received preventive services compared to privately insured adults. For children in Medicaid, who generally are entitled to coverage of comprehensive health screenings, including well-child check ups, as part of the federally required EPSDT benefit, most but not all states reported to GAO that they monitored or set goals related to children's utilization of preventive services and had undertaken initiatives to promote their provision. Nine states reported that they did not monitor children's utilization of specific preventive services. Forty-seven states reported having multiple initiatives to improve the provision of preventive services to children. For adults in Medicaid, for whom states' Medicaid coverage of preventive services is generally not required, most states reported to GAO that they covered most but not all of eight recommended preventive services that GAO reviewed. Nearly all state Medicaid programs, 49 and 48 respectively, reported covering cervical cancer screening and mammography, and three-quarters or more states reported covering four other preventive services. Two additional recommended services--intensive counseling to address obesity or to address high cholesterol--were reported as covered by fewer than one-third of states. For children in Medicaid, CMS oversees the provision of preventive services through state EPSDT reports and reviews of EPSDT programs, but gaps in oversight remain; for adults, oversight is more limited. For children, state reports showed that, on average, 58 percent of Medicaid children who were eligible for an EPSDT service in 2007 received one; far below the federal goal of 80 percent. CMS reviewed only 11 state EPSDT programs between April 2001 and June 2009. Few states reporting low rates of service provision were reviewed. CMS guidance to states may also have gaps: a 2006 study raised concerns that providers may not be aware of coverage of obesity-related services for Medicaid children. CMS has recognized the need for but has not yet begun drafting guidance on such coverage. For adults, CMS has provided some related guidance to states, but not on the reviewed preventive services.