Transcript UCSF Center to Address Disparities in Children*s Oral Health

What Does ObamaCare
Mean for Emerging Adults?
M. Jane Park, MPH
National Adolescent & Young Adult Health Information Center
Division of Adolescent and Young Adult Medicine,
Department of Pediatrics, UCSF Benioff Children’s Hospital,
University of California, San Francisco
October 11, 2013, Chicago
Society for the Study of Emerging Adulthood
6th Biennial Conference
Thank you to:
• Colleagues:
• Sally Adams, PhD, RN, Claire Brindis, DrPh, Charles E.
Irwin, Jr., MD, Josephine Lau, MD, Jazmyn Scott,
MPH; UCSF
• Abigail English, JD; Center for Adolescent Health and
the Law
• Funder:
• Maternal and Child Health Bureau, Health Services
and Resources Administration, USDHHS (Cooperative
Agreements: U45MC 00002 & U45MC 00023)
2
Presentation Overview
I. Part I, Background:
a. Health and health care for emerging adults
b. “Pre-ACA” health care system
II. Part II, The Affordable Care Act (ACA) and
emerging adults:
a. Public and private insurance
b. Benefits and confidentiality
3
Part 1: Background
• Why are health and health care important for
emerging adults?
• Pre-ACA Health Care System
• Access: How well could emerging adults gain
access to health care services?
• Utilization: What services
did youth receive?
• Unmet need: What didn’t
they receive?
4
Why are health and
health care important for
emerging adults?
5
Health Issues of Emerging
Adulthood
• The major health problems of emerging
adulthood are largely preventable.
• Many problems are linked to behaviors and
related outcomes.
• Few emerging adults have serious impairment
that interferes with daily functioning, BUT
• Those with chronic conditions, including mental
health disorders, must learn to manage these
conditions with increasing independence.
6
Critical Health Issues of
Emerging Adulthood*
• Increasing independence in habits related to
diet, physical activity, and sleep.
• Critical period to prevent chronic conditions of
adulthood, in areas such as
• Diseases related to tobacco use,
• Obesity,
• Dental caries, and
• Hearing loss.
*Adapted from the Healthy People 2020 Core Indicators for Adolescent and Young Adult Health
7
Critical Health Issues of
Emerging Adulthood
• Motor vehicle crashes &
drinking and driving.
• Violence, including homicide
& fighting.
• Reproductive & sexual health,
including behaviors to
prevent sexually transmitted
diseases, HIV/AIDS, and
unintended pregnancy.
8
Critical Health Issues of
Emerging Adulthood
• Critical period for mental
health concerns, such as:
• depression,
• suicide.
• Substance use, including
binge drinking and use of
marijuana & other illicit
drugs.
9
Most markers of adolescent health
worsen in emerging adulthood.
Many measures peak, including:
• Fatal motor vehicle crashes and homicide,
• Most measures of substance use/abuse,
• Drinking and driving, and
• Many sexually transmitted diseases.
Park et al., 2006
10
Mortality by Cause and Sex,
Ages 20-24, 2010
160
140
Other
133.48
Motor Vehicle
Suicide
120
Homicide
100
80
60
47.56
40
20
0
CDC Wonder
Male
Female
11
Mortality among males by Cause and
Race/Ethnicity, Ages 20-24, 2010
300
250
245.62
Other
Motor Vehicle
200.23
Rates per 100,000
200
Homicide
Suicide
150
123.19
97.86
100
55.06
50
0
American
Indian/Alaska Native
Black
White
Hispanic
Asian/Pacific Islander
CDC Wonder
12
Past-Month Substance Use, Ages 18-25,
by Sex, 2011
70%
63%
60%
59%
50%
40%
30%
38%
Males
29%
20%
Females
25%
23%
15%
17%
10%
0%
Cigarettes
Alcohol
Marijuana
Any Illicit Drug
National Survey on Drug Use and Health, 2011
13
Heavy Past-Month Alcohol and Cigarette Use,
by Sex, Ages 18-25, 2011
50%
46%
45%
40%
34%
35%
30%
Males
25%
20%
17%
14%
15%
Females
17%
8%
10%
5%
0%
Daily Cigarette Use
Binge Drinking
Heavy Alcohol Use
NSDUH, 2011
14
Chlamydia—Rates by Age and Sex,
United States, 2011
15
Gonorrhea—Rates by Age and Sex,
United States, 2011
16
Disparities and Special
Populations
• Major disparities & differences in health
status persist among youths.
• Special populations include:
•
•
•
•
•
Youth exiting foster care,
Sexual minority youth,
Homeless/runaway youth,
Incarcerated youths, and
Youth with chronic
conditions/special needs.
17
Emerging Adults (18-25) reporting any
Activity Limitation from any
Condition, by Sex, 2012
40%
35%
30%
25%
20%
15%
10%
7%
5%
5%
0%
Male
Female
National Health Interview Survey, 2012
18
Prevalence of Chronic/Special
Conditions among Emerging Adults
(18-25), 2011
20%
20%
16%
16%
12%
8%
5%
5%
4%
0%
Hypertension
Asthma
Currently Pregnant
Obese (BMI>=30)
National Health Interview Survey, 2011
19
25%
Past-Year Mental Health and Substance Use
Disorders, Emerging Adults (18-25), by Sex,
2010
Male
22%
20%
15%
Female
20%
14%
12%
12%
9%
10%
6%
5%
5%
0%
Serious Psychological
Distress
Major Depressive Episode
Alcohol Abuse/
Dependence
Drug Abuse/
Dependence
National Survey on Drug Use and Health, 2010
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Why is Health Care Important?
• Many emerging adults are beginning to:
• assume responsibility for their care, and
• learn to navigate the health care system.
• Developmentally-based health care may help:
• reduce mortality and morbidity - including incidence
of chronic illnesses - by decreasing health-damaging
behaviors & promoting healthy behavior, and
• improve management of chronic conditions/special
needs.
21
Pre-ACA:
System Issues
Access
Utilization
Unmet need
22
Health Care for Emerging Adults
• The current system falls short in many
respects:
• The financing system is difficult to navigate
and leaves many out;
• System is geared towards acute care over
preventive services and chronic disease
management;
• Virtually no formal clinical training focusing on
emerging adults.
NRC/IOM, 2008; Park et al., 2006
23
Reaching 18:
New roads, Few maps
• Health care system changes abruptly
at age 18:
• Change in legal status: can legally consent
to own care.
• Loss of eligibility for public insurance and
parents’ insurance (this is getting better).
• Limited models for transition to adult
health care (some exceptions).
• A few populations have organizational
structure for care (e.g., military, prison,
college health).
24
Reaching 18:
New roads, Few maps
•
Emerging adults and families generally not
prepared to navigate this change.
•
Action to ease this transition before the
ACA:
•
37 states passed some “dependent
coverage” law allowing emerging adults
to stay on their parents’ plan past 18
•
Medicaid allowed states to extend
coverage of youths aging out of the foster
care system past 18.
25
Are there clinical guidelines
for emerging adults?
• Little professional focus or consensus.
• Most adult guidelines are specific to disease (e.g.,
diabetes, heart disease) not age.
• Prevention: No single source of recommendations like
Bright Futures for the pediatric population.
• US Preventive Services Task Force (USPSTF) finds strong
evidence supporting preventive services in several areas,
such as tobacco, sexual health, and mental health.
• Bright Futures recommends screening for ages 18-21 in
areas with less evidence (e.g., injury & illicit drug use).
Hagan, Shaw & Duncan, 2008; Ozer et al., 2012
26
Consensus on services for
adolescents with special needs
• Transitional care for youth with special
health care needs (YSHCN):
• Developmentally appropriate,
• Coordination of responsibilities,
• Planned transition, and
• Consistent and uninterrupted chronic care
management
AAP, AAFP, & ACP- ASIM, 2002
27
Pre-ACA:
System Issues
Access
Utilization
Unmet need
28
29
Percent Insured by Age Group &
Type, 2011
100%
Full Year Private
Full Year Public
Uninsured Partial Year or Full Year
90%
80%
70%
60%
56.7%
51.5%
50%
40%
33.2%
32.6%
30%
20%
11.7%
15.2%
10%
0%
Adolescents 10-17
Emerging Adults 18-25
National Health Interview Survey, 2011
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No Usual Source of Health Care
by Sex & Age, 2012
Males
35%
Females
33%
30%
25%
21.0%
20%
15%
10%
6%
5%
4.8%
0%
Adolescents (10-17)
Emerging Adults (18-25)
National Health Interview Survey, 2011
31
Pre-ACA:
System issues
Access
Utilization
Unmet need
32
Where Emerging Adults
Access Care
Any Health Care Utilization
72%
Office-Based Visits
55%
Hospital Outpatient Visits
7%
ER Visits
15%
Inpatient Hospitalizations
6%
Prescription Medications
48%
Dental Visits
34%
Medical Expenditure Panel Survey, 2009
33
Health Care Service Utilization by
Age Group, 2009
97%***
100%
90%
88%***
89%***
83%***
% had utilization
80%
78%***
72%
70%
60%
50%
40%
30%
20%
10%
0%
Age 0-11
Age 12-17
Age 18-25
Age 26-44
Age 45-64
Age 65+
Medical Expenditure Panel Survey, 2009
34
Office-Based Service Utilization
by Age Group, 2009
100%
91%***
90%
% had utilization
80%
79%***
77%***
68%***
70%
60%
65%***
55%
50%
40%
30%
20%
10%
0%
Age 0-11
Age 12-17 Age 18-25 Age 26-44 Age 45-64
Age 65+
Medical Expenditure Panel Survey, 2009
35
ER Utilization by Age Group, 2009
30%
% had utilization
25%
20%
15%
17%
15%
15%
12%**
12%**
12%***
10%
5%
0%
Age 0-11 Age 12-17 Age 18-25 Age 26-44 Age 45-64 Age 65+
Medical Expenditure Panel Survey, 2009
36
Pre-ACA:
System issues
Access
Utilization
Unmet need
37
Emerging Adults (19-29) Experiencing Past-Year
Access Problems Due to Cost, 2011
Insured all year
Insured now, time uninsured in past year
Uninsured now
60%
50%
48%
50%
43%
40%
40%
36%
35%
30%
30%
20%
40%
19%
16%
16%
13%
10%
0%
Did not fill a prescription
Skipped recommended Had a medical problem,
test, treatment, or follow- did not visit doctor or
up
clinic
Did not get needed
specialist care
Commonwealth Fund Health Insurance Tracking Survey of US Adults, 2011
38
Past Year Treatment (%) among those with selected
problems, ages 18-25 with Problem, by Sex, 2010
Drug
Abuse/Dependence
13%
8%
Male
Alcohol
Abuse/Dependence
Female
7%
6%
Major Depressive
Episode
36%
55%
Serious Psychological
Distress
23%
36%
0%
10%
20%
30%
40%
50%
60%
National Survey on Drug Use and Health, 2010
39
Unmet Need: Low Provision of
Preventive Services
Preventive Counseling Provided to Emerging Adults
in Ambulatory Visits, Ages 20-29, 1996 to 2006
All Specialties
Primary Care
Ob/Gyn
Any
30.6%
32.7%
33.6%
Injury
2.4%
3.1%
0.8%
Smoking
3.1%
4.2%
3.1%
Exercise
8.2%
9.4%
8.2%
Weight reduction
3.0%
3.8%
3.4%
Mental health
4.1%
4.2%
1.3%
STD/HIV
2.7%
2.6%
7.1%
Diet
10.0%
12.4%
12.4%
Adapted from “Ambulatory Care Among Young Adults in the US”, Fortuna, et al., 2009
40
Transitional Care for Youths with
Special Health Care Needs
• In 2009-2010, 39.4% of youth with
special health care needs (ages 15-17)
received services necessary to make
appropriate transitions to adult health
care, work and independence.
National Survey of Children with Special Health Care Needs, 2010
41
Part II:
The Affordable Care Act
and
Emerging Adults
42
ACA Goals
• Stronger Consumer Rights and
Protections.
• More Affordable Coverage.
• Better Access to Care.
• Stronger Medicare.
See: : http://www.whitehouse.gov/healthreform/healthcare-overview.
43
Part II: The ACA
• How does the ACA affect emerging adults’
access to public and private insurance?
• How does the ACA affect services available for
emerging adults?
– Prevention
– Benefits
– Confidentiality
44
The Affordable Care Act
(ACA) and Emerging Adults
• No exclusions for pre-existing conditions.
• Individual insurance mandate.
• Major expansions of private insurance.
• Major expansion of public coverage (Medicaid) will
be decided on a state-by-state basis.
• Improved access to services, through:
• Essential health benefit packages.
• No cost-sharing for certain preventive health services.
English & Park, 2012
45
ACA: Individual Mandate
• Individuals will be required to have health
insurance (public or private), or face a financial
penalty, effective 2014.
• Individuals who do not have to file income tax
returns are exempt.
• The penalty will be the greater of:
– $95 or 1% of income, in 2014;
– $325 or 2% of income, in 2015; and
– $695 or 2.5% of income, in 2016 and
thereafter.
English & Park, 2012
46
Private Insurance
and the ACA
47
The Marketplace
• By January 2014, state-based marketplaces
(“insurance exchanges”) will begin covering
individuals and small groups:
• The Marketplace is required to create a seamless
enrollment process.
• Marketplaces can be run by: the state, the federal
government, or jointly run by both.
• All plans sold through the Marketplace must cover
ten “essential health benefits” in their package.
English & Park, 2012
48
The Marketplace
• Consumers are eligible for federal
subsidies for plans purchased from the
Marketplace:
• Cost-sharing subsidies for those with incomes
100% - 250% Federal Poverty Level (FPL)
(paid directly to health plan).
• Premium assistance for those with incomes
100% - 400% FPL (through tax credits).
English & Park, 2012
49
The Marketplace
• The Marketplace will also offer Catastrophic
Plans for adults (up to age 30):
• Low premium, high deductible;
• Must cover at least three primary care visits
and preventive services not subject to
deductible;
• May be an attractive low-cost option;
• BUT those with sudden serious illness or injury
will incur tremendous costs.
English & Park, 2012
50
Private Insurance:
Age 26 Provision
• Most private plans must offer dependent
coverage for emerging adults up to age 26.
• Applies regardless of young person’s
financial, marital, or student status.
• About 3 million emerging adults (ages 1925) gained coverage from 9/2010 to
12/2011.
English & Park, 2012; Sommers, 2012
51
Public Insurance
and the ACA
52
Public Insurance Prior to the ACA
• Under Federal law, Medicaid coverage of lowincome adults (including emerging adults) was
quite limited.
• State Medicaid programs could not cover most lowincome adults, unless they were parents, pregnant,
or had a disability.
• States may choose to expand Medicaid to
cover all adults with incomes up to 133% FPL.
• Under the 2012 Supreme Court decision, states not
choosing this expansion will not face the penalty (of
losing all Medicaid funds) in the original ACA
legislation.
English & Park, 2012
53
MAP of State Medicaid Decisions
54
Public Insurance & The ACA
• States must maintain the Medicaid eligibility
levels that were in place when the ACA was
enacted until 2014, for adults.
• All Medicaid programs must cover youth aging
out of Foster Care until age 26, effective 2014.
• New benefit: States may create “Health
Homes,” that would cover a range of services
for Medicaid beneficiaries (all ages) with one
or more chronic conditions.
English & Park, 2012
55
ACA INSURANCE COVERAGE FOR ADULTS
Medicaid
Income Levels
Expansion States
Non-Medicaid
Expansion States
>250% - 400% FPL
400%= Individual: $45,960
Family of 3: $78,120
Premium Assistance in
Marketplace
Premium Assistance in
Marketplace
>133% - 250% FPL
250%= Individual: $28,725
Family of 3: $38,775
Premium Assistance and
Cost-Sharing Subsidies in
Marketplace
Premium Assistance and
Cost-Sharing Subsidies in
Marketplace
100% - 133% FPL
Medicaid Coverage
for most adults
133%= Individual: $15,282
Family of 3: to $20,628
Less than 100% FPL
100%=
Individual: <$11,490
Family of 3: <$15,510
No Change from Pre-ACA
Medicaid Coverage
(ranges from 0% to 129% FPL,
depending on state and group)
FPL = Federal Poverty Level ( 2013 levels) See CMS, 2013
The ACA:
Benefits &
Confidentiality
57
Essential Health Benefits
• Marketplace plans must cover ten “Essential Health
Benefits”; the specific package will vary by state.
• Medicaid expansion programs (where states choose
this) must offer these benefits to newly eligible
adults.
•
•
•
•
•
ambulatory patient services;
emergency services;
hospitalization;
maternity and newborn care;
mental health and substance
abuse disorder services,
including behavioral health
treatment;
• prescription drugs;
• rehabilitative and
habilitative services and
devices;
• laboratory services;
• preventive and wellness and
chronic disease
management; and
• pediatric services, including
oral and vision care.
See: https://www.healthcare.gov/glossary/essential-health-benefits/
58
Preventive Services and the ACA
• Most private plans plans must cover certain
preventive services, with no cost-sharing. These
include:
• USPSTF grade [A] or [B] recommendations,
• Bright Futures recommendations for children and
adolescents,
• CDC ACIP vaccination recommendations, and
• Services included in the Women’s Preventive Health
Service Guidelines.
See: https://www.healthcare.gov/what-are-my-preventive-care-benefits/
59
Preventive Services and the ACA
• Preventive services include screening and
counseling in areas especially relevant for emerging
adults, including:
•
•
•
•
•
•
•
Depression,
Alcohol misuse,
Tobacco,
Diet & obesity,
Sexually Transmitted Infections and HIV,
Contraception***, and
Domestic and interpersonal violence.***
***Women only
See: https://www.healthcare.gov/what-are-my-preventive-care-benefits/
60
Confidentiality:
New challenges to an old concept
• Major changes in how patient data are stored and
shared, e.g., Explanation of Benefits (EOBs) &
Electronic Medical Records (EMRs).
• Changes meant to improve care and inform
consumers.
• BUT, these also can inform parents of sensitive
services received by their dependents.
• As more emerging adults are covered by Age 26
Provision, confidentiality may be compromised.
61
Confidentiality: Some solutions
• In NY & Wisconsin, plans not required to send
an EOB when no additional payment is
required for services.
• Health care systems are designing systems to
protect confidentiality in multiple areas of
operation, including:
– online appointing,
– lab and pharmacy procedures, and
– electronic medical records and billing.
English, Gold & Nash, 2012; Anoshiravani et al. 2012
62
Take home points:
EAs, Health & Health Care
• Emerging adults have unique health care
needs.
• The health care system changes abruptly
and significantly at age 18:
• Few recommendations
focus on this transition
and emerging adults’
health care needs.
• Transition especially
difficult for vulnerable
groups.
63
Take Home Points:
EAs, Health & Health Care
• Emerging adults traditionally have had low
rates of
• Having insurance and
• Receiving primary & preventive care.
• Emerging adults traditionally have had high
rates of
• Emergency room visits and
• Unmet need for health care services.
64
Take Home Points: The ACA
– In the Private market:
• Expanded options through Marketplace,
including premium and cost-sharing
assistance and Catastrophic Plans.
• Extended dependent coverage.
– Expanded Medicaid Coverage at state
option:
• Major insurance gap among the poor in
states no choosing the expansion.
65
Take Home Points: ACA
• Requirements related to benefits.
• Ten essential health benefits.
• Preventive services without cost-sharing.
• Challenges ensuring confidentiality.
66
References/Further Reading
Journal Articles & Research Briefs:
•
American Academy of Pediatrics, American Academy of Family Physicians and
American College of Physicians-American Society of Internal Medicine. A consensus
statement on health care transitions for young adults with special health care needs.
Pediatrics, 2002;110:1304-6.
•
Anoshiravani A, Gaskin GL, Groshek MR, Kuelbs C, Longhurst, CA. Special
Requirements for Electronic Medical Records in Adolescent Medicine, J Adolesc
Health, 2012;51(5): 409-414.
•
Collins SR, Robertson R, Garber T, Doty MM. Young, Uninsured, and in Debt: Why
Young Adults Lack Health Insurance and How the Affordable Care Act Is Helping;
Findings from the Commonwealth Fund Health Insurance Tracking Survey of Young
Adults, 2011. Washington, DC: The Commonwealth Fund, 2011.
•
English A., Gold RB, Nash E., Levine J. (2012). Confidentiality for Individuals Insured as
Dependents: A Review of State Laws and Policies. New York, NY: The Guttmacher
Institute. Available at: http://www.guttmacher.org/pubs/confidentiality-review.pdf
67
References/Further Reading
Journal Articles & Research Briefs:
•
English A & Park MJ. (2012) The Supreme Court ACA Decision: What Happens Now
for Adolescents and Young Adults? CAHL, Chapel Hill & NAHIC, Division of Adolescent
and Young Adult Medicine, UC San Francisco. Available
at:http://nahic.ucsf.edu/download/the-supreme-court-aca-decision-what-happensnow-for-adolescents-and-young-adults/
•
Fortuna RJ, Robbins B, Halterman JS Ambulatory care among young adults in the
United States. Ann Intern Med. 2009;151(6):379-385.
•
Hagan JF, Shaw J, Duncan P. Bright Futures: Guidelines for Health Supervision of
Infants, Children, and Adolescents. 2008. Available
athttp://brightfutures.aap.org/3rd_Edition_Guidelines_and_Pocket_Guide.html
•
Irwin CE, Jr. Young adults are worse off than adolescents. J Adolesc Health.
2010;46(5):405-6.
•
Ozer EM, Urquhart J, Park MJ, Brindis CB, Irwin CE, Jr. Young adult guidelines: there
but can't be found, Arch Pediatr Adolesc Med, 2012;49:476-482.
•
Park MJ, Mulye TP, Adams SH, Brindis CD, Irwin CE, Jr.: The Health Status of Young
Adults in the US. J Adolesc Health, 2006;39:305-317.
68
References/Further Reading
Data sources:
•
Agency for Healthcare Research and Quality. Medical Expenditures Panel Survey,
2009. Available at: http://meps.ahrq.gov/mepsweb/
•
Centers for Disease Control and Prevention.
• CDC Wonder: Compressed Mortality/Population Data [Private Data Run].
Atlanta, GA: Author; 2009. Available at http://wonder.cdc.gov/mortSQL.html
• National Health Interview Survey, 2011. Available
at:http://www.cdc.gov/nchs/nhis.htm
• Behavior Risk Factor Surveillance System [CDC, BRFSS; online WEAT
database]. Available
at:http://apps.nccd.cdc.gov/s_broker/weatsql.exe/weat/index.hsql
• Sexually Transmitted Disease Surveillance, 2010. Atlanta: U.S. Department of
Health and Human Services; 2011. Available
at:http://www.cdc.gov/std/stats/
69
References/Further Reading
Data sources:
•
Centers for Medicare and Medicaid Services:
• 2013 Poverty Guidelines (for Medicaid & CHIP eligibility); Available at:
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/ByTopics/Eligibility/Downloads/2013-Federal-Poverty-level-charts.pdf
• 2013 Medicaid and CHIP Income Eligibility Standards; Available at:
http://www.medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward2014/Downloads/Medicaid-and-CHIP-Eligibility-Levels-Table.pdf
•
Child and Adolescent Health Measurement Initiative; The Data Resource Center
for Child and Adolescent Health. National Survey of Children with Special Health
Care Needs. Available at: http://childhealthdata.org/learn/NS-CSHCN
•
Driving safety: National Highway Traffic Safety Administration. Traffic Safety Facts
2010 Data: Alcohol-Impaired Driving, (DOT-HS-811-606) Washington, DC, April
2012. Available at: http://www-nrd.nhtsa.dot.gov/Pubs/811606.pdf
•
Substance Abuse and Mental Health Data Archive. National Survey on Drug Use
and Health [NSUDH online database]. (2012). 2010 NSDUH data. Available at:
http://www.icpsr.umich.edu/icpsrweb/SAMHDA/sdatools/resources
70
Speaker Contact Information:
M. Jane Park, MPH
Project Coordinator
National Adolescent and Young Adult
Health Information Center
University of California, San Francisco
Telephone: 415-269-4272
Email: [email protected]
NAHIC website: http://nahic.ucsf.edu/