Comparative study of the use of EPSDT and other preventive and curative health care services by children enrolled in Medicaid : final project synthesis report

55 Pages·1997·2.7 MB·English

by  Gavin, Norma I., 1950-

COMPARATIVESTUDYOFTHEUSEOFEPSDT
ANDOTHERPREVENTIVEANDCURATIVEHEALTHCARE
SERVICESBYCHILDRENENROLLEDINMEDICAH):
FINALPROJECTSYNTHESISREPORT
April2,1997
by
NormaI.Gavin,Ph.D.
ResearchTriangleInstitute
EliciaJ.Herz,Ph.D.
TheMEDSTATGroup
E.KathleenAdams,Ph.D.
RollinsSchoolofPublicHealth,EmoryUniversity
AnitaJ.Chawla,Ph.D.
TheMEDSTATGroup
MarilynEllwood,M.S.W.
MathematicaPolicyResearch
IanHill
HealthSystemsResearch,Inc.
BethZimmerman
HealthSystemsResearch,Inc.
JeffreyWasserman,Ph.D.
TheMEDSTATGroup
Acknowledgments
Theauthorswouldliketothankthemanyindividualswhocontributedtothisstudy.
First,wewouldliketothankLeighAnnAlbersandMiriamBernardinfromTheMEDSTAT
Groupforwritingsectionsofreportsfromwhichthisreportwasderived;KateSredl,Linda
Graver,DonaldSchroeder,andSeanKennedyfromTheMEDSTATGroupandDeoBench,
previouslyfromTheMEDSTATGroupandcurrentlyfromMathematicaPolicyResearch,for
theirprogrammingexpertise,withoutwhichwecouldnothavecompletedtheproject;andtothe
manysecretarialandadministrativestaffatthevariousorganizationsfortypingandgeneral
administration,whichweresoimportantforthesmoothcompletionofthestudy.
WewouldalsoliketothanktheTechnicalAdvisoryPanelfortheirmanyhelpful
suggestions. TheseindividualsincludeTheodoreJoyce,Ph.D.,fromtheNationalBureauof
EconomicResearch;SaraRosenbaum,J.D.,fromtheGeorgeWashingtonUniversity;Janet
PerloffPh.D.,fromtheStateUniversityofNewYorkatAlbany;CharlesHomer,M.D.,M.P.H.,
fromtheHarvardMedicalSchool;andDennisWilliams,fromtheStateofNorthCarolina.
Furthermore,wewouldliketothanktheStateandlocalareaofficialsandthehealthcare
providersatthevariouslocationsthatwevisitedduringoursitevisits. Theseindividuals,who
aretoonumeroustonamehere,providedinvaluableinformation,whichwehaveusedto
interpretthequantitativeresults.
FinallywewouldliketothanktheHealthCareFinancingAdministrationforfunding
thisprojectand,inparticular,FeatherDavis,Ph.D.,ourHCFAProjectOfficer,whohas
providedhelpfuloversightandguidancethroughouttheprogressofthestudy.
TableofContents
Tuge
1 Introduction i
1.1 LegislativeBackground
j
1.2 ObjectivesandMethodology 2
2 DescriptionofStateProgramsandTheImplementationofOBRA-89 4
2.1 EligibilityRequirements •_ 5
2.2 ProviderFeeSchedulesandParticipationRequirements 7
2.3 InformingandOutreach 9
2.4 EPSDTPeriodicitySchedules !.'!!!!"!!!!!!!!!.'!10
2.5 PreventiveCareOutsideofEPSDT 12
2.6 CoverageofDiagnosticandTreatmentServices 13
2.7 ManagedCare 13
3 ChildHealthProviders....: 14
3.1 Physicians 14
3.1.1 PhysicianParticipation 14
3.1.2 ShortageAreas 16
3.1.3 PracticeVolumeandServiceConcentration 17
3.1.4 EffectsofMedicaidFeesandOtherIncentives 18
3.2 Institutionalproviders 20
3.3 PlaceofService 21
3.4 Dentists 21
4 Children'sHealthCareUseandExpenditures 22
4.1 MedicaidExperience 22
4.1.1 EPSDTParticipationandOverallPreventiveCareVisitRates 22
4.1.2 Immunizations 25
4.1.3 ProblemIdentification,Treatment,andReferral 26
4.1.4 DiagnosticandTreatmentServices 29
4.1.5 DentalServices 32
4.1.6 Expenditures 34
4.2 ComparisonofMedicaidtoPrivatelyInsuredandUninsuredChildren 35
4.2.1 PreventiveCareVisits 35
4.2.2 Immunizations 37
4.2.3 ProblemIdentification,Treatment,andReferral 38
4.2.4 DiagnosticandTreatmentServices 39
4.2.5 DentalServices 41
4.2.6 Expenditures 42
5 Conclusions 43
References 4g
. 1
ListofTables
Page
1. SelectedMedicaidIncomeEligibilityThresholds
asaPercentoftheFederalPovertyLevel 6
2. IndexofMedicaid-to-PrivatePaymentLevelsbyTypeofService 8
3. NumberofRecommendedWell-ChildVisitsAccordingto
4. AverthaegeACAoPunPteyr-iLodeivceiltyRaStcihoesduolfethaendNutmhebeStratoefECPhiSlDdTMeSdcirceaeindinEgnrSoclhleedeusles 1
totheNumberofParticipatingPhysiciansAmongCounties
withatLeastOneParticipatingPhysicianbyTypeofService 15
5. AverageMedicaidChildCaseloadsandAverageTotalMedicaidPayments
forChildrenAmongParticipatingPediatricians 17
6. HerfindahlIndexesforOffice-BasedPhysicians
ServingMedicaidChildrenbyTypeofService 18
7. ImpactofMedicaidFeesandOtherProgramChanges
ontheProbabilityofPhysiciansProvidingPreventiveCareandEPSDTScreens
andontheNumberofChildrenServedbyPhysicians 19
8. NumberofInstitutionalProvidersServingChildrenbyTypeofInstitution 20
9. AverageMedicaidChildCaseloadsandAverageTotalMedicaidPayments
forChildrenAmongParticipatingClinics 20
10. PercentageofMedicaidPaymentsforAmbulatoryVisits
PaidtoOffice-BasedPhysiciansbyTypeofVisit 21
11 AverageCounty-LevelRatiosoftheNumberofChildMedicaidEnrollees
totheNumberofParticipatingDentists,AverageMedicaidChildCaseloads
andAverageTotalMedicaidPaymentsforChildrenAmongParticipatingDentists ...22
12. PreventiveCareParticipationandVisitRatesBased
onAllMedicaid-PaidWell-ChildVisitsandtheAAPPeriodicitySchedule 23
13. EstimatedImpactofOBRA-89ProvisionsontheProbability
ofAnyWell-ChildVisitsandtheNumberofVisitsAmongChildrenwithVisits
forChildrenunderThreeYearsofAge 24
14. ImmunizationCompletionRatesBasedonAllMedicaid-Paid
ImmunizationsandtheAAPPeriodicitySchedule 26
15. EstimatedImpactofOBRA-89ProvisionsontheProbabilityofAnyChildhood
ImmunizationsandtheNumberofImmunizationsAmongChildrenwith
ImmunizationsforChildrenunderThreeYearsofAge .27
16. PercentageofChildrenwithHealthCareNeedsIdentifiedDuring
EPSDTScreeningVisitsandthePercentageofEPSDTScreeningVisits
withHealthCareNeedsThatWereTreatedand/orReferred 28
17. PercentageofMedicaidChildrenwithAnyDiagnosticandTreatment(D&T)
VisitsandAnyPrescriptionDrugsandtheNumberofD&TVisits
andPrescriptionsAmongUsersofTheseServices 29
18. PercentageofChildrenwithAnyHospitalStaysandOtherHealthServices
andtheNumberofHospitalStaysandDaysAmongChildrenwithHospitalStays....30
19. EstimatedImpactofOBRA-89ProvisionsontheProbabilityofAnyDiagnostic
andTreatment(D&T)VisitsandtheNumberofD&TVisitsAmongChildren
20. ComwbiithneVdisEitsstimatedImpactofOBRA,-89ProvisionsontheProbabilityofAny 3j
PrescriptionDrugsandHospitalStaysandtheNumberofPrescriptionsand
HospitalDaysAmongChildrenwithAnyUseofTheseServices 31
21. PercentageofChildrenwithAnyDentalCareandNumberofDentalClaims
PerPerson-YearEnrolledAmongChildrenwithAnyDentalCare 33
22. EstimatedImpactofOBRA-89ProvisionsontheProbabilityof
AnyDentalCareandtheNumberofDentalClaimsAmongChildrenwithClaims....33
23. TotalMedicaidExpendituresforChildren
andPercentageChangefrom1989to1992 34
24. MedicaidExpendituresPerChildEnrolleeandPerChildPerson-YearEnrolled
andPercentageChangefrom1989to1992 35
25. PreventiveCareParticipationandVisitRatesbyHealthInsurance
andIncomeCategory,1987NationalMedicalExpendituresSurvey 36
26. CompletionRatesforBasicChildhoodImmunizationsbyHealthInsurance
andIncomeCategoryAmongChildrenUnderSixYears,
1992NationalHealthInterviewSurvey 37
27. PhysicianContactsbyHealthInsuranceandIncomeCategory,
1988and1991NationalHealthInterviewSurveys .39
28. HospitalEpisodesbyHealthInsuranceandIncomeCategory,
1988and1991NationalHealthInterviewSurveys .40
29. DentalCareIndicatorsbyHealthInsuranceandIncomeCategory
AmongChildrenAgedTwotoSixYears,1991NationalHealthInterviewSurvey....41
30. LevelofCareandTotalAverageHealthCareExpendituresbyHealthInsuranceand
IncomeCategory,1987NationalMedicalExpendituresSurvey 42
1 Introduction
TheEarlyPeriodicScreening,DiagnosisandTreatment(EPSDT)programisan
ambitiouspediatriccomponenttotheMedicaidprogram. Establishedin1967,EPSDTprovides
comprehensive,periodicevaluationofhealth,developmental,andnutritionalstatus,aswellas
tyviehsariroosung,ohfhteahagerei.envgTa,lhaueantpdirodonegnartnaaldmssacclrrseoeeepnnriionnvggisdseeerrsvviiscceeerssv,.icteToshaelnlepcMreeisdmsiaacrrayyidtg-ooeacnlorroorlfelctethdehcephariloltgdhrrpearnmofbirsloetmomsbdieirtdteehcntttiof2i1ed
correctableconditionsearlysothatmoreserioushealthproblemsandmorecostlyhealthcare
servicescanbeavoided.
However,sinceitsinception,theprogram'ssuccessinscreeningandtreatingeligible
childrenhasfallenshortofexpectations. Theseshortfallsarecausedbyavarietyof
gfuaacrtdoiranss-maanndytoofthwehistcrhucrteulraeteotfotthheemheedailctahlcasryes-tseemektihnegybmeuhsatviaocrceosfs.MeOdtihcearisdrcehlaitledrteonparnodgrtahemir
factors,suchasinsufficientoutreach,inadequateproviderparticipation,andvariablecoverage
Mwaecedrrioecssarietdqh-ueeilrSitegadittbeoslecoopfveberorstoohnnssl;cyrtedheeiranegifnnoogrseat,incdsoatmnrdeeatstremreevanittcmesesen,rtvsisucecershv.iacseFsophrtyhesaxitacwamelprloeer,moapcrnciduoparatttooiroy1n9af8lo9rtahSleltraatpeys
rSteaqtueisreadndfowretrreealtimmeinttedofincenrutamibnecronadnidt/ioorndsudriastcioonveirnedotdhuerriSntgataess.creSetna,tewsewreerneoatlcsoovaelrleodweindstoome
seteligibilityrequirementsforprovidersofEPSDTscreens. SomeStatesrestrictedthese
sasleelrrvvmiiaccneedssatttooompruyabnlsyiccrMeheeendaiilnctghaiscdeerncvthieicrlesdsroeirnn.pornoevildoecrastiwonh.oTwheerseearbelsetrtioctdieomnosnrsetdruacteedtthheeabaivlaiitlyabtioliptryovoifde
ToincreaseEPSDTparticipationandtoimprovechildren'shealthstatus,Congress
aidndcrleusdsedmsaenvyeraolfpthreosveispiroonbslienmatthiecOpmrnoigbruasmBfuacdtgoerst.ReTchoinscrielpioarttiosnynAtchtesoifze1s98th9e(fOiBndRiAn-gs89o)fathat
four-yearstudyfundedbytheHealthCareFinancingAdministration(HCFA)thatinvestigated
theimpactsoftheseprovisionsonchildren'shealthserviceuseandexpenditures.
1.1 LegislativeBackground
Eachyearfrom1984through1990,Congressenactedlegislationexpandingboth
mandatesandoptionsforMedicaideligibilityofchildren(Gavin,1992). Thenewlaws
nadodwrersesqeudirbeodthtotuhesefisneapnacriaatleainndcocamteegtohrriecsahloleldisgifboirliMteydriecqauiidreemleignitbsiloitfytfhoerpcrhoigldrraemnfSrtoamtetshaorsee
usedforthecashassistanceprogramsandtocoverallchildrenmeetingthefinancial
carboenouqrdulnicdhraofietplmetderirnoetSnnsea,pultnlryedegmecarborevdsreilxre3s0yps,eraoe1rfg9snf8aoa3nfmtiianlwgyefoasmimtnierlunfciatemausirnlewdi.ietisBnhfwyiainnt1tch9so9iim0nne,csfSoatbmmaeietllseioseuwswptewthrioetehF1re3eid3qneucprieoarrmlecedpesontvtouepocrfottvyotehl1ree8vaF5lelPlpLce(hrFicPlSeLdtnr)atetnoesf
theFPLandchildrenbornonorbeforeSeptember30,1983uptoage21yearsinfamilieswith
incomesuptotheState'sAidtoFamilieswithDependentChildren(AFDC)incomeeligibility
Tlehveelleorg,isilfattihveeSitnaitteiahtaisveasamlesdoicpaelrlmyitnteeeddSytaptreosgtroamd,rouppatsosetthetemsetsdiacnadlltyodnieserdeygairndcootmheerlifmiintancial
resourcesindeterminingMedicaideligibilityforpregnantwomenandchildren.
Inaddition,thelegislativeinitiativessoughttobroadenandstrengthenthebenefitsthat
achnidlddriesanbrileicteyi-vreeltahtreodusgehrvMiecdeis.caiIdn.parTthiecusleari,niOtiBaRtiAve-s8a9ddrreeqsusierdedboSttahtpesretvoenmtaikveecsacrreeeannidngillness-
servicesavailabletochildrennotjustatperiodicintervalsbutwheneverachildissuspectedof
havingaphysical,mental,ordevelopmentalproblemorconditionthatrequiresanassessment
furtherdiagnosis,ortreatment. ThelawalsorequiredStatestoprovideallmedicallynecessary
serviceseligibleforFederalfinancialassistancetochildrenwhoseperiodicorinterperiodic
screensrevealproblems,eveniftheservicesarenototherwisecoveredundertheState's
Medicaidplan. Inaddition,OBRA-89codifiedregulationstorequirethatscreening,vision,
hearinganddentalservicesbeprovidedatintervalsthatmeet"reasonablestandardsofmedical
anddentalpractice";mandatedStatestodevelopdistinctperiodicityschedulesforroutinehealth
vision,hearing,anddentalscreens;requiredStatestoscreenallchildrenagesonetofiveyears
andothersatriskforleadpoisoning;andplacedrenewedemphasisontheprovisionofhealth
educationandanticipatoryguidanceinscreeningvisits.
OBRA-89alsoaddressedincentivesforproviderparticipationinMedicaid. Statesare
generallyrequiredtosetreimbursementratesforMedicaid-coveredservicesatlevelsthatensure
comparableserviceavailabilitytothatofthegeneralpopulationwithinthesamegeographicarea-
toguaranteecompliancewiththelaw,OBRA-89codifiedthisprovisionforobstetricaland
pediatricservices. ThisprovisionofOBRA-89isoftenreferredtoasthe"equalaccess"
psertovoifsisocnr.eenFiunrgt,hedriamgonroes,isO,BaRnAd-t8r9eatamlelnotwesderqvuiacleisfiteodpparratcitciitpiaotneeirnstwhheoEpPrSoDviTdeprloegssratmh.anTthheesfeull
amendmentswereintendedtoencouragealargernumberofpediatriciansandmorespecialists,
suchasdevelopmentalpsychologists,toparticipateinEPSDT.
Furthermore,OBRA-89establishedFederalauthoritytosetState-specificperformance
standardsfortheEPSDTprogram. Inresponsetothislatterprovision,theSecretaryofthe
DEStePaptSaeDrstTwmeearnmetoenoxfgpHeaecllatleetdlhitgaoibnrldeedHMuuecdemiatchnaeiSddeirfcvfhieicrleedsnrce(enDbbHeyHtfwSie)sceanslettyheaeaigrroa(anlFnYou)fal8190p9ap5re.triccTeionpatatpciaocrnotmripactilepiasathnidotnhtiihsneg8o0al'
percentgoalbyone-fiftheachyearfromFY1990toFY1995.
1.2 ObjectivesandMethodology
ThisstudyinvestigatedtheimpactoftheOBRA-89provisionsontheEPSDTprograms
andthehealthstatus,serviceuse,andexpendituresofMedicaidchildreninfour
States—California,Georgia,Michigan,andTennessee. Initially,thestudyhadfourmajor
components:(1)casestudiesofthefourStatestodeterminehowtheyoperatetheirEPSDT
programsandhowprogrampolicieschangedasaresultoftheOBRA-89legislation;(2)apre-
pyoesatrabneafloyrseisOBofRcAh-i8ld9rewna'ssMaeddoipctaedi)dauntidli1z9at9i2on(tahnedfierxspteynedairtuirnewshuiscihngthcelaOiBmRsAd-at8a9foprro1v9i8s9io(ntshe
werefullyimplemented);(3)apre-postanalysisofthesupplyofchildhealthproviders
participatinginMedicaidandEPSDTalsousingclaimsdatafor1989and1992;and(4)an
analysisofnationalsurveydatatodeterminehowthehealthstatusandhealthcareutilizationand
perxipoerndtiotaunrdesfoolflMoewdiincgaOiBdRcAh-il8d9r.enAdifffieftrhedcofmrpomontehnotseooffthoethsetrucdhyilsdurbesneqiunetnhtelyUnwiatsedadSdtaetdestoboth
measureparticipationamongdentalprovidersforMedicaidchildreninthefourstudyStatesand
tWoeinavlessotiugsaetdeathperei-mppoascttdoefsidgenntaanldprMoevdiidcearisdupclpaliymosndaMteadifcoraitdhecsheiladnraleyns'essu.seofdentalservices
The studyaddressednumerousquestionssurroundinghowthefourStateschangedtheir
MedicaidprogramsinresponsetotheOBRA-89provisionsrelatingtochildrenandtheimpact
thesechangeshadonchildren'shealthserviceuseandexpenditures. Inparticular,we
investigatedthefollowingquestions:
• HimopwacdtidditdhtehfeosuercShtaantgeesschhaanvgeeotnhetihreenliugmibbielrityanrdeqtuhierceommepnotssiftoirocnhiolfdernernol,laenddcwhhialdtren?
• HowdidthefourStateschangeproviderparticipationrequirementsandreimbursement
levels,andwhatimpactdidthesechangeshaveonproviderparticipationandchildren's
accesstocare?
• gHeonewradlidantdheEfPouSrDSTtastcersecehnainnggesetrhveicpersoviinspiaorntiocfulparre,vaenntdivwehactariemupnadcetrdMidedtihceaseidchiannges
haveonthepercentageofchildrenwithanypreventivecareandthepercentageof
childrenincompliancewithnationalstandardsonpreventivecareforchildren?
• HowdidthefourStateschangecoveredservicesforchildrenintheirMedicaidprograms,
andhowdidthisimpactthetypesofproblemsforwhichchildrenwerereferredfor
furtherdiagnosisandtreatmentandthenumberandtypesofserviceschildrenutilized?
• Howdidallofthesechangesineligibility,benefits,andproviderincentivesimpact
expendituresforMedicaid-coveredservicesamongchildren?
• HowdidtheuseofpreventiveandcurativehealthcareservicesbyMedicaidchildren
comparetothatofprivatelyinsuredanduninsuredchildreninlow-incomeandmiddle-to-
hOiBgRhA-i-n8c9omperofvaimsiiloiness?andhowdidthesecomparisonschangeafterimplementationofthe
8
Thisreportisasynthesisofourfindings. WefirstpresentadescriptionoftheMedicaid
programsinthefourstudyStatesandtheStates'responsestotheOBRA-89provisionsrelatin*
tochildren'sMedicaidcoverageandtheEPSDTprogram. Inthefollowingtwosections,we
penrreoslelnetdthcheirledsruelnt,sroefspoeucrtiavneallyy.seWseoftthheenipmuptatchtesoefrtehseusletsreisntpoonasneastoionnaplarctoincitpeaxttinbgyprreovviiedweirnsgand
theresultsofthenationalsurveydataanalysesinthenextsection. Finally,wedrawallthis
informationtogethertoanswereachofthequestionsposedaboveintheconcludingsection.
2 DescriptionofStateProgramsandTheImplementationofOBRA-89
ThefourstudyStates-California,GeorgiaMichiganandTennessee—werechosenfor
thisstudybecauseofthereadyavailabilityoftheirMedicaidclaimsdata.1 AlthoughtheseStates
arenotnecessarilyrepresentativeofallStateMedicaidprograms,theyareamongthelargest,
bothintermsoftotalrecipientsandtotalexpenditures(Herzetal.,1995). In1989and1992'
ptehersceenftouorfStottaatlesMetdogiectahiedreaxcpceonudnitteudrefso.raCbaoliuftoornniea-qwuiatrhtetrheoflaarllgeMsetdSitcataeidMerdeciicpaiiedntpsraongdra1m7-1
nationwideaccountedforthemajorityoftheserecipients(60-62percent)andexpenditures(57
percent).
eitherMeThdiiscarreepoorrtafoMceudsiecsaoindMceadpiitcaatieddpenrrooglrlaeemsaunnddewrh2o1hyaedarnsotofreasgiedewdhionwaelroengn-otteernmrcoalrleedorin
othermedicalinstitutionduringthestudyyear. Thesechildrenconstitutedanincreasingmajority
ofMedicaidrecipients;inthefourstudyStates,theyrepresented53-59percentoftheMedicaid
ppMeoerpdcuielcnaattiiadonncdhiiCnlad1li9pf8oo9prunalinaadtait5o5n4-2b6e0pteprwecereencnte.n1t9Ii8nn9M1ia9cn9hd2i.g1a9Gn9e,2ortahgtiis6a6peopxpepurelcraeitntei,onncfeordleltmhoaewiengderedbaytreeTsletatniinnvecesrlyseaesseteaabitlne4t7his
withagrowthrateofonly4percent.2 Althoughtheycomprisedamajorityoftherecipient
population,thesechildrenaccountedforonly19-28percentoftotalMedicaidexpendituresin
ThestudyStatesdifferedinsignificantways,bothwithregardtotheirMedicaidcoverage
OfoBrRcAhi-l8dr9enpraonvdistihoenisr.EPSDTprograms. Thesedifferencesledtodifferentialresponsestothe
Theprimarydatasourceforthefour-StateanalyseswastheTape-to-Tapedatabase Thisdatabase
GSitnracotlueuspdefusrnoadlmelrc1la9a8is0mersti,ehsernoorufoglchlomn1et9nr9at2c,.tasTnfdhreopmrcolHvaiCidmFesAra.dnadtaenfrroolmlmtehentMdeadtiacawiedreMpauntaginetmoeunntifIonrfmorfmoartmiaotnbSyysTtheemsMEinDtSheTsAeT
pMeedriccean.td—2sctOailnplietwaertleeladsbopelnlanwoswh.ythHMeoiwrcaehtvieesgrai,nn'ttshheeraiotntecholeufrsitinhocrnreeeoafssttehueidnsyetShctihasitelpsdo.rpeunlaotniloyniinscsroealsoewstishethgeroewxctlhusraitoentoof1c3hildrenin
2.1 EligibilityRequirements
ThestudyStates'pre-expansionfinancialeligibilitystandardsrangedfromthehighestto
amongthelowestinthenation. CaliforniahadthehighestAFDCincomethresholdinthe
continentalUnitedStatesin1989andwassecondonlytoVermontin1992;California's
medicallyneedyincomethresholdwasthehighestamongtheStatesandterritoriesinbothyears.
However,theincomestandardsinCaliforniawereunchangedfrom1989to1992. Therefore,the
State'sAFDCincomethresholdforafamilyofthreeexpressedasapercentoftheFPLfellfrom
85percentto72percentoverthestudyperiod. Similarly,themedicallyneedyincomethreshold
forafamilyofthreeinCaliforniafellfrom113percentoftheFPLin1989to97percentofthe
FPLin1992.
TheincomestandardswerelowerintheotherthreeStates. In1989,theAFDCincome
thresholdexpressedasapercentoftheFPLwas70percentinMichigan,50percentinGeorgia,
and47percentinTennessee,andthemedicallyneedyincomethresholdswere67percent,45
percent,and30percentinthethreeStates,respectively. Michigan,whichhadapooreconomy
andStatebudgetcrisisin1991,actuallyreduceditsincomethresholdsfortheAFDCprogram.
However,theothertwoStatesincreasedtheirincomethresholdsduringthestudyperiod. The
AFDCandmedicallyneedyincomethresholdsincreasedslightlyover2percentinGeorgiafrom
A19F8D9Ctoi1n9c9o2m,eatnhdreTsehnonledssbeye,10wpheircchenhtadbutthemaldoweesntoicnhcaongmeessitnanidtsarmdesdiicna1l9l8y9n,eiendcyreianscedomiets
threshold. Nevertheless,noneoftheMedicaideligibilitythresholdsinthefourStateskeptpace
withtheincreaseintheFPL(Table1).
Theimplementationofthepoverty-relatedexpansionsalsovariedintimingandextent
amongthestudyStates. TennesseewasoneofthefirstStatestotakeadvantageofthe1987
OmnibusBudgetReconciliationAct(OBRA-87)expansioncoverageoptionforpregnant
women,infants,andyoungchildren. BecauseitsincomethresholdsforMedicaidwerealready
nearthepovertylevel,CaliforniadidnotmoveasquicklyasotherStatestoexercisetheOBRA-
87Medicaidexpansionoptionsforchildren. By1989,Tennesseecoveredchildrenunderage
sevenwithfamilyincomesupto100percentoftheFPL;Georgiacoveredchildrenunderage
tpherreceenltivoifngthbeeFloPwLtahnedFcPhLi;ldarnednuMnidcehrigaagnecthorveeereindfianmfialnitsesinwiftahmiilnicesomweisthupintcoom10e0spueprcteon1t8o5fthe
FPL.InJuly1989,CaliforniachosetoextendMedicaidtopregnantwomenandinfantswith
familyincomesupto185percentoftheFPL,buttheStatehadnotexercisedtheoptiontoextend
Medicaidtoolderchildren.
By1992,allfourStatescoveredchildrenuptoagesixwhowerelivingbelow133
percentoftheFPL,andallotherchildrenbornafterSeptember30,1983infamilieswithincomes
upto100percentoftheFPL,asmandatedinOBRA-90. Inaddition,allstudyStates,except
Georgia,coveredinfantsinfamilieswithincomesupto185percentoftheFPLin1992;Georgia
coveredinfantslivingbelow133percentoftheFPL.