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What Does ObamaCare Mean for Emerging Adults? M. Jane Park, MPH National Adolescent & Young Adult Health Information Center Division of Adolescent and.

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Presentation on theme: "What Does ObamaCare Mean for Emerging Adults? M. Jane Park, MPH National Adolescent & Young Adult Health Information Center Division of Adolescent and."— Presentation transcript:

1 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 6 th Biennial Conference

2 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

3 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

4 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? 4 Utilization: What services did youth receive? Unmet need: What didn’t they receive?

5 Why are health and health care important for emerging adults? 5

6 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

7 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. 7 *Adapted from the Healthy People 2020 Core Indicators for Adolescent and Young Adult Health

8 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

9 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

10 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. 10 Park et al., 2006

11 11 CDC Wonder

12 12 Mortality among males by Cause and Race/Ethnicity, Ages 20-24, 2010 CDC Wonder

13 Past-Month Substance Use, Ages 18-25, by Sex, 2011 13 National Survey on Drug Use and Health, 2011

14 Heavy Past-Month Alcohol and Cigarette Use, by Sex, Ages 18-25, 2011 14 NSDUH, 2011

15 Chlamydia—Rates by Age and Sex, United States, 2011 15

16 Gonorrhea—Rates by Age and Sex, United States, 2011 16

17 Disparities and Special Populations Youth exiting foster care, Sexual minority youth, Homeless/runaway youth, Incarcerated youths, and Youth with chronic conditions/special needs. 17 Major disparities & differences in health status persist among youths. Special populations include:

18 18 National Health Interview Survey, 2012

19 19 National Health Interview Survey, 2011

20 20 National Survey on Drug Use and Health, 2010 Past-Year Mental Health and Substance Use Disorders, Emerging Adults (18-25), by Sex, 2010

21 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

22 Pre-ACA: System Issues Access Utilization Unmet need 22

23 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. 23 NRC/IOM, 2008; Park et al., 2006

24 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 ? ? ? ? ? ? ?

25 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 ? ? ? ? ? ? ?

26 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). 26 Hagan, Shaw & Duncan, 2008; Ozer et al., 2012

27 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 27 AAP, AAFP, & ACP- ASIM, 2002

28 Pre-ACA: System Issues Access Utilization Unmet need 28

29 29

30 Percent Insured by Age Group & Type, 2011 30 National Health Interview Survey, 2011

31 No Usual Source of Health Care by Sex & Age, 2012 31 National Health Interview Survey, 2011

32 Pre-ACA: System issues Access Utilization Unmet need 32

33 Where Emerging Adults Access Care Any Health Care Utilization72% Office-Based Visits55% Hospital Outpatient Visits7% ER Visits15% Inpatient Hospitalizations6% Prescription Medications48% Dental Visits34% 33 Medical Expenditure Panel Survey, 2009

34 34 Health Care Service Utilization by Age Group, 2009 % had utilization Medical Expenditure Panel Survey, 2009

35 35 Office-Based Service Utilization by Age Group, 2009 % had utilization Medical Expenditure Panel Survey, 2009

36 36 ER Utilization by Age Group, 2009 % had utilization Medical Expenditure Panel Survey, 2009

37 Pre-ACA: System issues Access Utilization Unmet need 37

38 Emerging Adults (19-29) Experiencing Past-Year Access Problems Due to Cost, 2011 38 Commonwealth Fund Health Insurance Tracking Survey of US Adults, 2011

39 39 National Survey on Drug Use and Health, 2010 Past Year Treatment (%) among those with selected problems, ages 18-25 with Problem, by Sex, 2010

40 Unmet Need: Low Provision of Preventive Services Preventive Counseling Provided to Emerging Adults in Ambulatory Visits, Ages 20-29, 1996 to 2006 All SpecialtiesPrimary CareOb/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% Adapted from “Ambulatory Care Among Young Adults in the US”, Fortuna, et al., 2009 40

41 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. 41 National Survey of Children with Special Health Care Needs, 2010

42 Part II: The Affordable Care Act and Emerging Adults 42

43 ACA Goals Stronger Consumer Rights and Protections. More Affordable Coverage. Better Access to Care. Stronger Medicare. See: : http://www.whitehouse.gov/healthreform/healthcare-overview.http://www.whitehouse.gov/healthreform/healthcare-overview. 43

44 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

45 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. 45 English & Park, 2012

46 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

47 Private Insurance and the ACA 47

48 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

49 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

50 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

51 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 19- 25) gained coverage from 9/2010 to 12/2011. English & Park, 2012; Sommers, 2012 51

52 Public Insurance and the ACA 52

53 Under Federal law, Medicaid coverage of low- income adults (including emerging adults) was quite limited. State Medicaid programs could not cover most low- income 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 Public Insurance Prior to the ACA 53

54 MAP of State Medicaid Decisions 54

55 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 Public Insurance & The ACA

56 100% - 133% FPL 133% = Individual: $15,282 Family of 3: to $20,628 >133% - 250% FPL 250%= Individual: $28,725 Family of 3: $38,775 >250% - 400% FPL 400%= Individual: $45,960 Family of 3: $78,120 Medicaid Coverage for most adults Premium Assistance and Cost-Sharing Subsidies in Marketplace Premium Assistance in Marketplace No Change from Pre-ACA Medicaid Coverage (ranges from 0% to 129% FPL, depending on state and group) Premium Assistance and Cost-Sharing Subsidies in Marketplace Less than 100% FPL 100%= Individual: <$11,490 Family of 3: <$15,510 Premium Assistance in Marketplace Income Levels Medicaid Expansion States Non-Medicaid Expansion States FPL = Federal Poverty Level ( 2013 levels) See CMS, 2013 ACA INSURANCE COVERAGE FOR ADULTS

57 The ACA: Benefits & Confidentiality 57

58 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

59 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. Preventive Services and the ACA See: https://www.healthcare.gov/what-are-my-preventive-care-benefits/ 59

60 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 Preventive Services and the ACA

61 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

62 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. 62 English, Gold & Nash, 2012; Anoshiravani et al. 2012

63 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: 63 Few recommendations focus on this transition and emerging adults’ health care needs. Transition especially difficult for vulnerable groups.

64 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

65 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

66 Take Home Points: ACA Requirements related to benefits. Ten essential health benefits. Preventive services without cost-sharing. Challenges ensuring confidentiality. 66

67 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.pdfhttp://www.guttmacher.org/pubs/confidentiality-review.pdf 67

68 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-happens- now-for-adolescents-and-young-adults/http://nahic.ucsf.edu/download/the-supreme-court-aca-decision-what-happens- now-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.htmlhttp://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

69 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.htmlhttp://wonder.cdc.gov/mortSQL.html National Health Interview Survey, 2011. Available at:http://www.cdc.gov/nchs/nhis.htmhttp://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.hsqlhttp://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/http://www.cdc.gov/std/stats/ 69

70 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/By- Topics/Eligibility/Downloads/2013-Federal-Poverty-level-charts.pdf 2013 Medicaid and CHIP Income Eligibility Standards; Available at: http://www.medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward- 2014/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-CSHCNhttp://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.pdfhttp://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 http://www.icpsr.umich.edu/icpsrweb/SAMHDA/sdatools/resources 70

71 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: jane.park@ucsf.edujane.park@ucsf.edu NAHIC website: http://nahic.ucsf.edu/http://nahic.ucsf.edu/


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