Shaping the Future: Family Planning and Reproductive Health Services for Males Within Health Care Reform

1. Shaping the Future: Family Planning and Reproductive Health Services for Males Within Health Care Reform Claire Brindis, Dr. P.H.* , Charles E. Irwin, Jr. M.D.*Abigail English, J.D.^ Jane Park, M.P.H.* and John Urquhart, B.S. Executive Director, National Adolescent Health Information and Innovation Center Director, Bixby Center for Global Reproductive Health University of California, San Francisco ^ National Center for Adolescent Health and the Law 2011 National Conference for Male Family Planning and Reproductive Health Services June 16, 2011

3. Objectives • Describe the health and reproductive health care needs of adolescent and young adult males and implications for health reform. • Identify opportunities under health care reform to improve the health of young men, including:   • prevention, • medical home, • extended health care coverage up to age 26, and • elimination of pre-existing health conditions (among others). • Identify opportunities to advocate for young men’s health within the health care reform environment, including assurance of confidentiality, access to integrated systems of care, multiple points of entry, and continuity of care.

4. WHY HEALTH CARE FOR YOUNG MEN? • Special opportunities for health care system to improve the health of adolescents and young adult men. • Increasingly responsible for daily health habits, such as diet , exercise, tobacco, drugs/alcohol, which has life long implications. • Greater role in managing chronic conditions . • Adolescents may experiment in ways that may jeopardize their health in the short-term and contribute to chronic disease in adulthood. • Ideally, health care services can help adolescents adopt healthy habits and behaviors, avoid health-damaging behaviors, manage chronic conditions and prevent disease. • Unfortunately, the health care system often falls short of this ideal, missing a special opportunity to improve health[IOM, 2008].

5. Why adolescents and young adults need policy makers’ attention… Adolescents /young adults ages 10-24 - diverse and growing. • Between 1990 - 2006, + from 40 to 63 million. • 55% White, non-Hispanic (NH); 17% Hispanic; 14% Black; 4% Asian/Pacific Islander; 0.9% American Indian/ Alaskan Native; and 10% other. • One in 10 were immigrants or foreign-born; Hispanic (64%) or Asian/Pacific Islander origin (21%). • An estimated 17% of adolescents ages 12 to 17 have a special healthcare need; 5% of young adults (ages 19–29) have a disabling chronic condition.

6. Health Conditions of Adolescents and Young Adults • Childbirth is the leading cause of hospitalization, followed by trauma and mental health disorders. • Youths ages 15 to 24 have the highest rate of visits to emergency departments, after ages <4 and >75. • Critical period – identify & treat mental health problems – symptoms of ¾ of lifetime diagnosable problems by age 24. • Depression is a major risk factor both in terms of contributing to suicide, as well as substance abuse and risky sexual behavior.

7. Overview • Health Profile: • Mortality • Behaviors • Chronic Conditions/Health Outcomes • Health Care Services

8. Adolescent and Young Adult Health • Majority of morbidity and mortality is related to risky behaviors and mental health issues. • Rates of homicide, unintentional injury, substance use, drinking and driving, sexually transmitted infections, and childbearing peak during adolescence and young adulthood. Examples: • Mortality: over 7 in 10 deaths for ages 10-24 result from motor vehicle accidents (MVA), homicide, and suicide. • 15-24 year olds account for half of all new STIs each year; 14% of all new HIV diagnoses occurs among this age group.

9. Overall Mortality by Gender & Age Group, Ages 10-24, 2007 Crude rates per 100,000 Source: CDC WONDER, 2007

10. Unintentional Injury Mortality by Age Group and Gender, Ages 10-24, 2007 Crude rates per 100,000 Source: CDC WONDER, 2007

11. Homicide, by Age Group and Gender, Ages 10-24, 2007 Crude rates per 100,000 Source: CDC WONDER, 2007

12. Suicide, by Age Group and Gender, Ages 10-24, 2007 Crude rates per 100,000 Source: CDC WONDER, 2007

14. Behaviors • Substance Use • Sexual Behaviors • Injury-related Behaviors • Violence

15. Any Past 30-day Substance Use, by Substance and Gender, High School Seniors, 2009 Source: Youth Risk Behavior Surveillance System, 2009

16. Sexual Behaviors, by Gender, High School Students, 2009 Source: Youth Risk Behavior Surveillance System, 2009

17. Contraception Use/Protection During Last Sexual Intercourse, by Gender, Currently Sexually Active High School Students, 2009 Source: Youth Risk Behavior Surveillance System, 2009

18. Chronic Conditions/Health Outcomes • Overweight • Eating Disorders • Asthma • Mental Health • Sexually Transmitted Infections

19. Prevalence of Common Chronic Conditions in Adolescents Sources: Overweight: Ogden, C. L., Carroll, M. D., Curtin, L. R., Lamb, M. M., & Flegal, K. M. (2010). Prevalence of High Body Mass Index in US Children and Adolescents, 2007-2008., see: CDC's health data interactive: Vomiting & pills, 2009 YRBS

20. Prevalence of Common Chronic Conditions in Adolescents, continued Sources: The Journal of the American Medical Association, 303 (3), 242 – 249; Asthma & ADD/ADHD: National Health Interview Survey, 2007-2009

21. Major Depressive Episode Source: Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (May 11, 2009).

22. Past-Year Suicide Attempts, by Gender, High School Students, 2009 Source: Youth Risk Behavior Surveillance System, 2009

23. Chlamydia—Rates by Age and Sex, United States, 2009 Men Rate (per 100,000 population) Women 3,800 3,040 2,280 1,520 760 0 0 760 1,520 2,280 3,040 3,800 Age 10–14 13.8 127.9 15–19 735.5 3,329.3 20–24 1,120.6 3,273.9 25–29 573.3 1,234.0 30–34 286.0 511.7 35–39 141.3 205.8 81.9 88.4 40–44 45–54 36.0 32.0 11.0 9.1 55–64 65+ 2.9 2.1 Total 219.8 593.4

26. Health Care Services • Doctors Visits • Hospital Visits

27. Disparities among Adolescents and Young Adults • Even among high-income groups and those with private insurance, disparities exist—12% of Hispanics, as compared to 5% of Whites, reported problems obtaining needed medical care. • Immunization rates for three adolescent-specific vaccines have improved, from 25%-32% in 2007 to 37%-41% in 2008. For the “catch up” vaccines, are more encouraging, with rates for two of these vaccines reaching the Healthy People 2010 target of 90% for ages 13-15 (MMWR-2010). • Potentially preventable hospitalizations – gaps exist across race/ethnic groups and within income groups. • Black children has at least 3 times the rate of asthma admissions than white children from every income group. • After controlling for community-level income, the difference between rates of diabetes admissions for Hispanic and white children remained significant.

28. Had Doctor Visit, Past Year (Besides Hospital, ER, or Surgery) Source: NHIS, 2009

29. Short-stay Hospital Discharge Rates by Gender and Type, Ages 10-19, Annual Average 1995-1997 Source: National Hospital Discharge Survey, 1995-1997, CDC

30. How do adolescents use services? Prevention, Content of Visits, and Anticipatory Guidance 38% of adolescents received a preventive services visit; Noncitizen children (44%) were less likely to have well-visits. Low-income and full-year uninsured were associated with higher risk for not receiving this visit: 19% for Hispanics with public insurance, as compared with 22% Blacks and 27% white children) (Irwin, et al, 2009). Children/adolescents in the West South Central (45%), East South Central (49%), and Mountain (50%) regions were less likely to receive services.

31. How do adolescents use services? Prevention, Content of Visits, and Anticipatory Guidance • Anticipatory guidance - 31% for seat belts, helmets, and secondhand smoke to 49% for healthy eating. Only 10% had all 6 prevention areas addressed. • 40% of adolescents had time alone with their providers: (42% for males vs. 37% of females). • Hispanic, younger females, and the lowest-income adolescents were the least likely to have time alone (Irwin 2009).

32. Clinical, Research & Policy Implications • Clinicians need to use gender as a critical factor in addressing health needs of adolescents/young adults • Prevention/Intervention Programs need to consider gender in development of programs • Data should be used to inform research and policy programs • Advocacy for attention to Males – “Office of Men’s Health”

34. What are the Numbers of Potentially Eligible Adolescents and Young Adults? • 5 million of the 8 million uninsured children are currently eligible for Medicaid or CHIP. • 36% are 13 ‐ 18 yr olds (1.7 million) • 13.7 million Uninsured Young Adults 19‐29: • Subsidized Coverage in Medicaid – 52% • Exchange - 41% • Will require subsidy to Purchase - 7% • Potential coverage of 32 million uninsured 2019 - • 50% Medicaid and 50% Private Health Insurance

35. Patient Protection and Affordable Care Act (ACA) • Adolescents and Young Adults on Parents’ health insurance program • Some States already launching programs even before the date required by ACA; others will change only when parents’ plans are up for renewal. • Expansion of Medicaid to low-income, single adults (up to 133% of poverty) • States are not required to expand for several years, although some states are opting to begin earlier. • Results in a patchwork of coverage • Greater disparities and significant differences in access to care among vulnerable populations. • Need to find ways to expand eligibility at the state level (if feasible).

36. Improving Access to Comprehensive Benefits – Private Insurance • Requires establishment of essential benefits package • ambulatory • emergency • hospitalization • rehabilitation and habilitative services/devices • lab • maternity and newborn • mental health and substance use disorder services • prescription drugs • preventive and wellness services • chronic disease management • pediatric services, including oral and vision care.

37. Medicaid and CHIP – Special Groups • Continue coverage for youth who age out of foster care until they reach age 26, if previously enrolled in Medicaid while in foster care. (2014) • Maintain current Medicaid and CHIP eligibility for those with incomes >133% FPL. • If states have insufficient funds to cover all eligible children/adolescents, refer to state health insurance exchange (private insurance plan) or evaluate for Medicaid coverage. • State option - Medicaid expansion of family planning (SPA) (2010)

38. Early Wins - No Pre‐Existing Exclusions • No coverage denials/exclusions for children/teens with preexisting conditions • Open enrollment agreed upon by administration and insurers to avoid adverse selection • No lifetime caps, restrictive annual limits or rescissions (Rating rules change in 2014)

39. Improving Access to Comprehensive Benefits – Private Insurance • Minimum essential benefit package to be determined (+,-) • Annual wellness visits – no co-pay • Prevention services without cost-sharing: • US Preventive Services Task Force (screening for tobacco use, alcohol abuse, sexually transmitted disease); • Immunizations; • Preventive Care -Bright Futures; • Additional screenings for women (HRSA-2011).

40. Apart from ACA- Investment in Prevention and Wellness • Increased Medicaid matching funds for states that provide coverage for preventive services without cost sharing. • Prevention and Public Health Trust Fund ($7 Billion over 5 years; total of $15 Billion). • Grant program to support delivery of evidence-based and community-based prevention and wellness services; reduce chronic disease rates; address disparities. • Home visiting program - $1.5 billion over 5 years. • CDC focus on tobacco, obesity, diabetes, teenage pregnancy prevention.

41. Training and Provider Compensation • Medicaid payments to 100% of Medicare rates for primary care physicians (2013; 2014). • Graduate Medical Education positions – Primary Care and General Surgery and states with lowest physician/population ratios. • Teaching Health Centers – community-based ambulatory patient care centers (2011). • Loan repayment; Scholarship and Loans; Primary Care Training; Mental and Behavioral Health Training Programs; Oral Health Professionals; NPs; Nursing Career Ladders (2011). • Training programs focused on primary care models; medical homes; team management of chronic diseases; integration of physical and mental health services (2010).

43. Challenges

44. Current Challenges – Outreach and Enrollment • How can we overcome current state financial limitations preventing current efforts to enroll nearly 5 million uninsured children who are eligible for Medicaid or CHIP? • What will happen to Undocumented Immigrants? • How will Non-citizen, legal immigrants (barred from enrolling during their first 5 years in U.S. (exception pregnant women and children) fare?

45. Challenges • Will penalties be sufficient to incentivize purchase of care? • Will comprehensive contraceptive services and supplies be mandated for inclusion as part of essential benefit package? • While plans will need to offer at least an essential benefit package, will premiums and level of cost sharing be significantly different under Exchange plans?

46. How do we assure confidentiality of care for adolescents and young adults? Why is confidentiality key? • Who’s Affected • Minor dependents • Young adults covered on parents’ policies • Women • Need for Confidentiality: • Substance Abuse • Mental Health • Domestic Violence • Reproductive Health Care • – Sexually transmitted infections • Pregnancy-related care • Abortion • Contraception • Potential impact of health care reform • More insured → more dependents • Increased age for dependent coverage

47. Challenges: Will planned tools work to cut red tape and Help Families/Individuals Navigate New System? • Intent for “no wrong door” between Medicaid, CHIP, and the exchange subsidies • Web‐based enrollment • Consistent eligibility rules • Plain language, simplified communications • Use of technology/systems • Consumer assistance • facilitate enrollment • access health care • troubleshoot problems (2010) • Navigators assist with public education and enrollment (2014)

48. Challenges – • Social Will/Shared Responsibility • Outreach and enrollment (access; ease; information): • State financial limitations • Undocumented Immigrants • Non-citizen, legal immigrants (barred from enrolling during their first 5 years in U.S. (exception pregnant women and children). • Consistency of implementation • Standardized Benefit Packages and Incentives to enroll • Confidentiality – Explanation of Benefits – (EOBs); Services • Coordination – Reconciliation of preventive guidelines; public and private systems of care; Role of Community health centers • Health Information Technology • Medical Homes

49. Challenge: How Health Plans, States and Advocates Collaborate towards successful implementation? • Public education on positive impact of ACA • Getting everyone covered • Strategic investments in technology • Effective coordination between public and private coverage • Independent, community‐based consumer assistance

50. Challenges • Controlling health care costs • Health insurance alone will not improve the health of young adults • Need to fully fund: • Outreach regarding importance of obtaining clinical preventive services and availability of coverage • Increase numbers of primary care and public health professionals • Community-based prevention and health promotion • Transition from current programs in place (Title V, Title X, Ryan White) to new environment • Undocumented immigrants will remain uninsured