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What Does ObamaCare Mean for Emerging A dults?

What Does ObamaCare Mean for Emerging A dults?. 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

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What Does ObamaCare Mean for Emerging A dults?

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  1. What Does ObamaCareMean 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

  2. Thank you to: • Colleagues: • Sally Adams, PhD, RN, Claire Brindis, DrPh, Charles E. Irwin, Jr., MD, Josephine Lau, MD, JazmynScott, 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)

  3. Presentation Overview • Part I, Background: • Health and health care for emerging adults • “Pre-ACA” health care system • Part II, The Affordable Care Act (ACA) and emerging adults: • Public and private insurance • Benefits and confidentiality

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

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

  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.

  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. *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.

  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.

  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. Park et al., 2006

  11. CDC Wonder

  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 National Survey on Drug Use and Health, 2011

  14. Heavy Past-Month Alcohol and Cigarette Use, by Sex, Ages 18-25, 2011 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. • Major disparities & differences in health status persist among youths. • Special populations include:

  18. National Health Interview Survey, 2012

  19. National Health Interview Survey, 2011

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

  22. Pre-ACA:System IssuesAccessUtilizationUnmet need

  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. 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). ? ? ? ? ? ? ?

  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. ? ? ? ? ? ? ?

  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). 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 AAP, AAFP, & ACP- ASIM, 2002

  28. Pre-ACA:System IssuesAccessUtilizationUnmet need

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

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

  31. Pre-ACA:System issuesAccessUtilizationUnmet need

  32. Where Emerging Adults Access Care Medical Expenditure Panel Survey, 2009

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

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

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

  36. Pre-ACA:System issuesAccessUtilizationUnmet need

  37. Emerging Adults (19-29) Experiencing Past-Year Access Problems Due to Cost, 2011 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 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 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 greaterof: • $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

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