Table Of Content

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.