Adolescents are among the healthiest populations in the nation, with relatively low rates of acute and chronic conditions and high self-reported health status. Despite enjoying good health, teens experience significant physiological and developmental changes during adolescence that shape their health decisions and needs. Puberty and burgeoning independence contribute to new experimentation and risky behavior. This issue module looks at the availability and access to appropriate and confidential health services for adolescents ages 12-18, insurance coverage and reform, the role of state and federal policies, as well as innovative models for delivering comprehensive care to this age group.
Adolescents in the U.S. also represent a demographically diverse population with the share of teens that are racial and ethnic minorities rising rapidly. Many adolescents are low-income; 40% are either poor or near-poor. Adolescents are at a vulnerable stage of development, and thus require specialized services from the healthcare system, support networks, educational organizations, and community.
Several risk factors commonly arise during adolescence, including new sexual behavior, violence and victimization, abuse of substances like alcohol and drugs, weight problems due to lack of physical activity or poor diet, and mental illnesses. Behaviors are influenced by the contextual environment of both school and community, and also differ by a teen’s race/ethnicity, family income, age, and gender.
Confidentiality and Consent
Confidentiality of care is a primary concern for many adolescents. Research has found that teenagers will go without care, withhold information about themselves, delay, or not seek help in order to keep their parents from finding out about a health issue. Confidentiality is interconnected with consent to care, through state laws dictating whether a minor can receive or access a health service without parental consent or notification and whether a doctor can tell parents about an adolescent’s health at their discretion. Insurance companies may contribute to a lack of confidentiality by sending an “Explanation of Benefits” (EOB) to the primary insurance holder, usually a parent, when a teenager seeks a healthcare service. This may deter teens from seeking important care for sensitive health concerns. States have a range of laws regarding consent for sensitive services such as reproductive and mental health care.
Reproductive Health
Substantial efforts and funding in adolescent health are focused on reproductive health services to reduce the incidence of teen pregnancy and STIs. Federal programs for sexual education include the Teen Pregnancy Prevention Program, the Personal Responsibility Education Program, the Abstinence-Only program which supports the promotion and education of abstinence until marriage. Access to family planning services is another important component of adolescent reproductive health. For low-income families, Medicaid covers the majority (71%) of public funding of reproductive health services. It operates in parallel with the federal Title X Family planning program, which is the only federal grant program specifically dedicated to providing community-based reproductive health and family planning services to teens and low-income women. Community clinics and family planning providers such as Planned Parenthood are often a primary site of care for low-income teens in need of reproductive health or counseling, family planning, contraceptive, and STI services for a number of reasons.
Coverage and Access
Children have the highest rate of coverage of any population, with 88% of adolescents and young adults covered by either private insurance or public programs.
- 60% of adolescents ages 10-18 are covered by private insurance. Private insurance plans have traditionally varied in what they offer in the way of services for this age group, but new rules established under health reform will set a minimum level of benefits that plans have to cover, including federally approved preventive services, such as vaccines, STI screenings, and counseling services.
- Medicaid and CHIP are the major forms of public coverage for low-income teens. Adolescents with public insurance may go to private doctors or clinics that accept Medicaid or CHIP. Medicaid coverage of preventive care is quite broad as a result of the Early Periodic Screening Diagnosis and Treatment (EPSDT) program which serves children and teenagers until age 21. However, access to Medicaid can also be limited due to a shortage of providers that accept Medicaid, stemming in part from the program’s low reimbursement rates. ,
- Approximately 4 million adolescents ages 10-18 lack health insurance; however, it is estimated that 65% of these adolescents are eligible for Medicaid/CHIP, but not enrolled. Adolescents without healthcare insurance or with gaps in coverage have worse access to needed health services, and half of uninsured adolescents have at least one unmet health need.
Nine in ten (92%) of adolescents report having a usual source of care. Like adults, however, adolescents also encounter a number of non-financial barriers to care, such as inadequate time with provider, lack of transportation, lack of continuity with a physician, racial, ethnic, gender and language-related barriers or inconvenient location of office. On the provider side, many healthcare professionals serving teenagers in the primary care settings report feeling unprepared to address an adolescent patient after a positive screening for drugs, behavioral, reproductive, or developmental issues. Despite efforts in the field of pediatrics to incorporate specialized training in adolescent health, the American Board of Pediatrics found only 17% of pediatricians think they are very well trained to care for adolescents.
Many experts have suggested models for broadening the healthcare workforce serving teens to include other professionals with expertise in adolescent health to work alongside clinicians in teams. In addition, there has been considerable attention to models of care such as Adoleschent health clinics and centers, which are mobile clinics or drop-in centers where specialists in adolescent health serve patients alongside a diverse staff of professionals. School-based health centers typically operate inside a school setting, usually with a staff of mixed training- medical assistants, nurse practitioners, social workers, psychologists, counselors, physicians, nutritionists, educators, case managers, and dentists.
Health Reform
The Affordable Care Act includes a number of provisions that will affect access to and quality of care for adolescents and young adults.
- Ban on pre-existing conditions - Insurance companies are no longer able to exclude children based on pre-existing conditions. (2010)
- Age extension of dependent coverage - Adolescents and young adults can remain on their parents’ insurance plan as dependents until age 26, assuring coverage during transition years to young adults. (2010)
- Extended eligibility for Medicaid and access to private coverage through state exchanges - The ACA will extend Medicaid coverage to all children in families with incomes below 138% of the poverty threshold, and subsidies will be available to obtain private health insurance coverage through State Exchanges for modest and moderate income families. (2014)
- Coverage of preventive services without cost-sharing - All new private plans will need to cover without cost sharing, all services recommended by the Bright Futures Guidelines, Rated A or B by the US Preventive Services Task Force, and immunizations recommended by the CDC as well as preventive services for women such as contraception. Adolescents will be newly eligible for Medicaid will get these services through the EPSDT program through age 21. (2010)
- Increasing Medicaid Reimbursement Rates - ACA includes federal funding to raise Medicaid payment rates to Medicare levels for primary care providers, including pediatricians. (2013)
The ACA has also set aside money for the following adolescent health issues: obesity, teen pregnancy prevention, family planning, Community Health Centers, and School Based Health Centers. Health reform addresses some of the challenges teens face in the healthcare system, and expansion of coverage and provider reimbursements have potential to improve access to services. Investing in preventive care for adolescents may help establish good health behavior at an early stage of life and have long term-effects on health and use of services later in life.
Prepared by Esme Cullen and Alina Salganicoff of the Kaiser Family Foundation, 2011.