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Shortchanging Preventive Healthcare

Ilana Novick

Despite all the coverage of battles over the Affordable Care Act's Medicaid expansion, one question has barely been asked: how will the expansion affect current Medicaid recipients? Will they have receive the same benefits, particularly access to preventive services and screenings that can mean the difference between a minor ailment and a major problem? 

Unfortunately, according to a recent report from George Washington University's School of Public Health  the answer may be no. The report is entitled "Existing Medicaid Beneficiaries Left Off the Affordable Care Act’s Prevention Bandwagon” and it suggests that while those covered under the Medicaid expansion will have lifesaving preventive services, those already enrolled in Medicaid are not guaranteed the same benefits, creating a kind of class system within those on Medicaid. 

The good news is that under the Affordable Care Act, Medicaid and Medicare will be required by law to cover a full range of crucial preventive services such as screening tests for colorectal cancer, high blood cholesterol, HIV infection, and diet counseling that can prevent obesity. But the bad news for those already enrolled in state Medicaid programs? Well according to the report, "state Medicaid plans are not required to cover such care for adults already enrolled in Medicaid."

The report reviewed Medicaid policies in all 50 states and Washington, D.C. from June-November 2012. The researchers found that in their current form most states do not cover all of the preventive services recommended by the U.S. Preventive Services Task Force. And in the grand tradition of indecipherable language for government documents, even the researchers couldn't always figure out exactly what was covered. The gaps they did find however, were often glaring. 

For example, mammograms are almost always covered by private insurance companies, but the report found not all Medicaid programs offered such care to existing beneficiaries. Even worse, "three states don’t cover preventive mammograms for this population at all—a shortfall that could mean low-income women will go without the test." Only 11 state Medicaid programs cover breast cancer susceptibility testing for the BRCA1 gene that increases the risk of breast and ovarian cancer. Only three states explicitly cover chemoprevention for such beneficiaries. 

The authors also found that many states will only provide coverage for heart disease, depression, or diabetes screenings if such screenings are deemed "medically necessary" which doesn't make sense because the term, however vague, applies to cases where a problem is already established, not to detect problems in an otherwise healthy person, which is the whole point of preventive screenings. Apparently, there's an income cut-off for being worthy of a diabetes or cancer screening. 

Those who are lucky enough to be added to Medicaid post-ACA expansion will get out of this problem, but as the law stands now, if you're already in a Medicaid program your preventive coverage will remain lacking. 

The authors suggest a few options for changes, but they are mostly voluntary: managed care plans could choose to cover services that save lives even if Medicaid doesn't require it, or all Medicaid providers could choose to follow the U.S. Preventive Services Task Force's guidelines even if Medicaid doesn't spell out that they have to.

The last suggestion, having Congress step in and require that current Medicaid recipients as well as those included in the expansion, should all have access to the same services, is the most important but faces an uphill battle given many states' rejection of the expansion. 

The fight for state-by-state Medicaid expansion should remain strong, but we shouldn't forget the people who are already covered, but remain in danger of not receiving the full benefits that the expansion would provide.