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Access to Care for Adolescents: Role of Financing and Policy

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.

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Access to Care for Adolescents: Role of Financing and Policy

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  1. 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

  2. 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

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

  4. 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.

  5. 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.

  6. 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

  7. 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 2007. www.covertheuninsured.org

  8. 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) • 12-17 year-olds, 2003: • 36% needed/ didn’t get mental health care • 10% needed/ had problems getting specialty care • 18-25 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. http://nahic.ucsf.edu/index.php/data/article/briefs_fact_sheets/

  9. 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

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

  11. 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

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

  13. Sources of Financing:Surprising Medicaid Facts • Medicaid (53m @ $329B) is bigger than Medicare (42m @ $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 15-17 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 2005. http://www.kff.edu; 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 2005 5(1);6-44.

  14. 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 2005. http://www.kff.edu; 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 2005 5(1);6-44.

  15. 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

  16. Sources of Financing:Public Health Resources • Title V MCH Block Grant • “30% Set-aside” toward primary/preventive care; <1/3 of states report that they do this • Year 2000 objectives for Adolescent health: • Births (per 1000) to 15-17’s; • MVA deaths (per 100,000) in 1-14’s; • % uninsured 0-18; • Suicides (per 100,000) in 15-17’s; • Percentage of Medicaid-eligibles who have received a Medicaid paid service • Optional measures: few are adolescent-specific; many states have none • Title X Family Planning • 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), 326-337

  17. 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

  18. Coverage and Spending Trends:Uninsured by Age and Income • Uninsured by age: • 13% among 12-17 year-olds • 11% among <12 year-olds • 28% among 18-24 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.

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

  20. Coverage and Spending Trends: Uninsured by Age -2003 Source: Coverage Matters-Insurance and Health Care - 2001 Percent Uninsured 2.1 million 2.9 million 1.3 million

  21. 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

  22. 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 $10K 16.6% • $10K - <$30K 34.0% • $30K - <$50K 21.5% • $50K - <$75K 6.4% • $75K and above 6.4% • Unmet need due to cost, 2002-03: • 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 2007. http://www.CoverThe Uninsured.org

  23. 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

  24. 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)

  25. 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 2006. www.childrenshealthcampaign.org

  26. Access and Financing for Adolescent Health: Resources • National Adolescent Health Information Center (NAHIC) http://nahic.ucsf.edu/ • American Academy of Pediatrics: Principles on Access www.aap.org • Campaign for Children’s Health Care: www.childrenshealthcampaign.org/tools • Commonwealth Fund: State Scorecard on Health System Performance http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=494551 • Georgetown University Health Policy Institute: Center for Children and Families http://www1.georgetown.edu/grad/gppi/hpi/ccf/schip/ • Cover the Uninsured: www.covertheuninsured.org

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