Access to Care for Adolescents: Role of Financing and Policy Laura P Shone MSW, DrPH Assistant Professor of Pediatrics and Clinical Nursing Director of Research, LEAH Fellowship Program Department of Pediatrics University of Rochester School of Medicine

Outline: Financing for Adolescent Health Where do teens go for health care? Why does it matter? Show me the money: Private and public sources of financing for adolescent health Coverage and Spending Trends Issues State-level Resources

Outline: Financing for Adolescent Health Where do teens go for health care?

Where Do Girls Receive Care? Overall Healthcare Utilization by Female Adolescents within a 1-Year Period Source: Albertin CS, Rand CM, Fryer EG, Shone LP, Szilagyi PG, Schaffer S. Adolescent Healthcare Utilization Across the U.S.: Who May Be Reached for Immunization? Poster Symposium: Immunization Delivery; presented at the annual meeting of the Pediatric Academic Societies, April 29, 2006, San Francisco, CA.

Where Do Boys Receive Care? Overall Healthcare Utilization by male Adolescents within a 1-Year Period Source: Albertin CS, Rand CM, Fryer EG, Shone LP, Szilagyi PG, Schaffer S. Adolescent Healthcare Utilization Across the U.S.: Who May Be Reached for Immunization? Poster Symposium: Immunization Delivery; presented at the annual meeting of the Pediatric Academic Societies, April 29, 2006, San Francisco, CA.

Outline: Financing for Adolescent Health Where do teens go for health care? Why does it matter? Show me the money: Private and public sources of financing for adolescent health Coverage and Spending Trends Issues State-level Resources

Why Does it Matter? Disparities in Unmet Need Source: Health Care Coverage in America: Understanding the Issues and Proposed solutions. Alliance for Health Reform, March

Why Does It Matter? Some Teens Don’t Get Care Older teens, young adults – worse with age Less likely to see MD or dentist in past year if: Ethnic / racial minority Lower income (<200% FPL) year-olds, 2003: 36% needed/ didn’t get mental health care 10% needed/ had problems getting specialty care year-olds, 2003: 36% of males / 20% of females had no USC 6% of males / 9% of females didn’t fill prescription due to cost Source: National Adolescent Health Information Center (NAHIC) 2008 Fact Sheet on Health Care Access and Utilization: Adolescents and Young Adults.

Outline: Financing for Adolescent Health Where do teens go for health care? Why does it matter? Show me the money: Private and public sources of financing for adolescent health Coverage and Spending Trends Issues State-level Resources

Show Me The Money: Financing for Adolescent Health Private Health Insurance Public Health Insurance Programs Public Health Insurance Programs Medicaid, SCHIP, SSD, Medicare Medicaid, SCHIP, SSD, Medicare Public Health Resources Public Health Resources Title V MCH Block Grant Title V MCH Block Grant Title X Family Planning, Planned Parenthood, etc Title X Family Planning, Planned Parenthood, etc Vaccines for Children (VFC) Vaccines for Children (VFC) Personal (out-of-pocket) spending Personal (out-of-pocket) spending Uncompensated or Charity Care Uncompensated or Charity Care e.g. NY State Bad Debt and Charity Care Pool e.g. NY State Bad Debt and Charity Care Pool

Show Me The Money: Sources of Private Financing Employer-linked health insurance “Group” market Wholesale prices Cost shared between employer/employee (variation) Self-purchased health insurance “Individual” market Retail prices Cost borne by individuals Many denials / exclusions – state regulation varies Both markets: Cost increases, high deductibles, coverage limits, denials

Show Me The Money: Sources of Public Financing Medicaid State Children’s Health Insurance Program (SCHIP) Social Security Disability (SSD) Medicare

Sources of Financing: Surprising Medicaid Facts Medicaid $329B) is bigger than Medicare $309B) Largest source of grant $$ to states Keeps private insurance costs down Children and adolescents are not the problem (<18 = 48% of enrollment but 18% of costs) $1,700 per child vs. $12,300 per disabled vs. $12,800 per elderly in 2003 “Optional” benefits matter for adolescents 3.7 – 4.7 per 1000 teens hospitalized for mood disorders, BUT Prescriptions medicines are optional Inpatient psychiatric care is optional for persons <21 Handouts: Key Facts: The Medicaid Program at a Glance. Kaiser Commission on Medicaid and the Uninsured. Publication #7236, January Amazing Medicaid Facts, the Commonwealth Fund Health Policy Week in Review, March 7, 2005; and non-handout Simpson L et.al. Health Care for Children and Youth in the United States: Annual Report on Patterns of Coverage, Utilization, Quality, and Expenditures by Income. Ambulatory Pediatrics Jan-Feb (1);6-44.

Sources of Financing: Medicaid for Adolescents Phase-in eligibility for adolescents <19 years Options to increase age or income limits 46 states exceeded phase-in limits by 2001 Coverage for teens improved with SCHIP Most states cover teens <200% FPL BUT may still have different income limits by age Traditional Medicaid serves 3x more teens than SCHIP, but more teens are covered by separate- program SCHIP than Medicaid-expansion SCHIP Handouts: Key Facts: The Medicaid Program at a Glance. Kaiser Commission on Medicaid and the Uninsured. Publication #7236, January Amazing Medicaid Facts, the Commonwealth Fund Health Policy Week in Review, March 7, 2005; and non-handout Simpson L et.al. Health Care for Children and Youth in the United States: Annual Report on Patterns of Coverage, Utilization, Quality, and Expenditures by Income. Ambulatory Pediatrics Jan-Feb (1);6-44.

Sources of Financing: SCHIP How it is like Medicaid Administrative overlap – joint application; means-tested; re- certification How it is different from Medicaid SCHIP is not an entitlement SCHIP match more favorable Greater state flexibility: cost-sharing, waiting periods/caps/freezes, option to extend eligibility, coverage or both; can cover immigrants with state $$ SCHIP more generous for adolescents, but not guaranteed

Sources of Financing: Public Health Resources Title V MCH Block Grant Title V MCH Block Grant “30% Set-aside” toward primary/preventive care; “30% Set-aside” toward primary/preventive care; <1/3 of states report that they do this <1/3 of states report that they do this Year 2000 objectives for Adolescent health: Year 2000 objectives for Adolescent health: Births (per 1000) to 15-17’s; Births (per 1000) to 15-17’s; MVA deaths (per 100,000) in 1-14’s; MVA deaths (per 100,000) in 1-14’s; % uninsured 0-18; % uninsured 0-18; Suicides (per 100,000) in 15-17’s; Suicides (per 100,000) in 15-17’s; Percentage of Medicaid-eligibles who have received a Medicaid paid service Percentage of Medicaid-eligibles who have received a Medicaid paid service Optional measures: few are adolescent-specific; many states have none Optional measures: few are adolescent-specific; many states have none Title X Family Planning Title X Family Planning Vaccines for Children (VFC) Vaccines for Children (VFC) McNulty, M. Adolescent health spending and measures in state Title V Maternal and Child health programs. J. Public Health Management Practice, 2003, 9(4),

Outline: Financing for Adolescent Health Where do teens go for health care? Why does it matter? Show me the money: Private and public sources of financing for adolescent health Coverage and Spending Trends Issues State-level Resources

Coverage and Spending Trends: Uninsured by Age and Income Uninsured by age: 13% among year-olds 11% among <12 year-olds 28% among year-olds Uninsured by income: (2001) 2.5 million or 21% of poor children (<18) 2 million or 46% of poor young adults (18-24) Current policies exclude some adolescents Inter-state variation in budgets, regulations, eligibility, coverage, monitoring/accountability Morreale MC and English A. Eligibility and enrollment of adolescents in Medicaid and SCHIP: Recent progress, current challenges. J Adolescent Health (2003) Vol. 32S;25-39.

Coverage and Spending Trends: Sources of Health Insurance Source: US Census 2003

Coverage and Spending Trends: Uninsured by Age Source: Coverage Matters-Insurance and Health Care Percent Uninsured 1.3 million 2.1 million2.9 million

Coverage and Spending Issues: Who is Most Likely to be Uninsured? Young adults (18-24’s) Low-income Families without wage earners, or blue-collar workers Low educational level Immigrants (non-citizens) Black or Hispanic Children of parents who are uninsured All of these are independently associated with being uninsured

Coverage and Spending Issues: Surprising Facts about Uninsured >46 million US uninsured all year in 2005 >8 of 10 uninsured are in working families Uninsured at all incomes: Under $10K16.6% $10K - <$30K 34.0% $30K - <$50K 21.5% $50K - <$75K 6.4% $75K and above 6.4% Unmet need due to cost, : 40% among insured 84% among uninsured 18,000 adults die/year because they are uninsured Health Care Coverage in America: Understanding the Issues and Proposed Solutions, Alliance for Health Reform, March Uninsured.org

Coverage and Spending Issues: Consequences of Being Uninsured Poorer access: Lack a medical home Less use of WCC Lower rates of utilization of: Primary care Specialty care ED care Greater unmet need: Delayed care Foregone care Poorer health outcomes: Lower immunization rates Less prenatal care Poorer birth outcomes: LBW and infant mortality

Coverage and Spending Issues: Where Do We Stand Now? Multiple stakeholders Private coverage decreasing Health care costs increasing Public funding threats Economic recession Benefit reductions Increased cost-sharing (premiums, co-payments, deductibles) Acute coverage and cost issues for young adults (18-24)

Why Health Insurance Matters For Children and Adolescents More likely to have medical home Better access to preventive care Better continuity of care Less unmet need Fewer racial/ethnic disparities Improve social-emotional development Better equipped to succeed in school Source: Families USA for the Campaign for Children’s Health Care: Why health Insurance Matters for Children. July

Access and Financing for Adolescent Health: Resources National Adolescent Health Information Center (NAHIC) American Academy of Pediatrics: Principles on Access Campaign for Children’s Health Care: Commonwealth Fund: State Scorecard on Health System Performance Georgetown University Health Policy Institute: Center for Children and Families Cover the Uninsured: