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Adolescent Health Services: Missing Opportunities 6 Health Insurance Coverage and Access to Adolescent Health Services SUMMARY More than 4 million adolescents aged 10–18 are medically uninsured. Uninsured rates are higher among the poor and near poor, racial and ethnic minorities, and noncitizens than among the general adolescent population. As is true for all Americans, medically uninsured adolescents are less likely to have a regular source of primary care and use medical and dental care less often compared with those who have insurance. The majority of medically uninsured adolescents aged 10–18 are eligible for public coverage but not yet enrolled. Their parents say they would enroll their children in public programs, but many do not know their children are eligible. Having health insurance does not ensure adolescents’ access to affordable, high-quality services given problems associated with high out-of-pocket cost-sharing requirements, limitations in benefit packages, and low provider reimbursement levels. For example, the current system for financing health insurance coverage leads to underinvestments in disease prevention and treatment in some areas that are particularly problematic for adolescents.
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Adolescent Health Services: Missing Opportunities The availability, nature, and content of health services for adolescents are profoundly affected by the ability to pay for those services through public and private health insurance. Fundamentally, money matters, and policies matter with respect to financing systems. This chapter focuses on these two contextual characteristics. It examines the extent to which adolescents have adequate insurance coverage for the health services they need; the emphasis is on financing issues and the public policies that relate to health insurance coverage. The discussion addresses limitations of the current financing system for adolescent health services with respect to both the lack of health insurance coverage and shortcomings of the coverage for adolescents who are insured. LACK OF HEALTH INSURANCE COVERAGE As is true for all Americans, adolescents who are medically uninsured often receive care late in the development of a health problem or not at all. As a result, they are at higher risk for hospitalization for conditions amenable to timely outpatient care and for missed diagnoses of serious and even life-threatening conditions (Institute of Medicine, 2002a). As discussed in Chapter 2, some conditions (e.g., injuries, asthma) are particularly important in the adolescent population, and without timely care, frequently lead to unnecessary hospitalization. Additionally, dental care accounts for only 4.4 percent of total U.S. health expenditures for the general population, but accounts for 29.2 percent of health expenditures among those aged 6–17 compared with 37.3 percent for all other ambulatory health services (Cohen et al., 1996). This section examines how a lack of health insurance relates to limitations in adolescents’ access to needed health services, reviews disparities in insurance coverage and eligibility for adolescents, and describes some approaches that could be used to address these issues. Access Those who lack health insurance are much more likely to go without health care than the insured (Institute of Medicine, 2001). The Institute of Medicine (IOM) has presented important evidence that being medically uninsured has a negative effect on health-related outcomes and chronic conditions among adults. The IOM study included a review of research investigating the health of working adults with and without health insurance (Institute of Medicine, 2002a). In a follow-up to that study, the IOM examined the impact of uninsurance on families, children, and adolescents. In this IOM study and other research, it was found that adolescents who lack health insurance coverage have worse access to needed health services than those who have coverage, although barriers remain for insured adoles-
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Adolescent Health Services: Missing Opportunities cents as well, as discussed later in this chapter (Callahan and Cooper, 2005; Ford, Bearman, and Moody, 1999; Institute of Medicine, 2002b; Klein et al., 2006; Lieu, Newacheck, and McManus, 1993; National Adolescent Health Information Center, 2005; Newacheck et al., 1999; Shenkman, Youngblade, and Nackashi, 2003; Yu et al., 2001). Gaps in insurance coverage, particularly for mental health and dental services, also appear to cause access problems (Olson, Tang, and Newacheck, 2005). Table 6-1 shows how access to care differs between adolescents who are medically insured and uninsured along a number of different dimensions: failure to get needed medical care because of cost, delays in getting needed care because of cost, failure to get needed prescription drugs because of cost, the absence of a usual source for health care, and failure to see a physician in the past year (tabulations based on data from the 2004–2005 National Health Interview Survey).1 For each measure, the medically uninsured are worse off than those with public or private coverage. For example, 13 percent of those aged 10–18 who were uninsured failed to get needed medical care and 11 percent to get needed prescription drugs because of cost, compared with 2.6 percent and 4.3 percent, respectively, for those with public coverage and 1.1 percent and 2.1 percent, respectively, for those with private coverage. Similarly, almost half of the medically uninsured in this age group lacked a usual source of care, and 41 percent had not seen a physician during the past year, compared with 6.6 and 14.4 percent, respectively, for those with public coverage and 3.6 and 11.8 percent, respectively, for those with private coverage. The discrepancy between levels of access to care enjoyed by the medically insured and uninsured is the greatest for those with poor health. Those with multiple risk factors can suffer quite severe limitations in access to care. Thus, 16.1 percent of uninsured adolescents aged 10–18 who reported fair or poor health status failed to get medical care because of cost in 2004–2005, compared with 5.3 percent of their counterparts covered by public insurance (tabulations based on data from the U.S. National Health Interview Survey, 2004–2005). According to the 2004 Medical Expenditure Panel Survey, three-fourths (76.4 percent) of U.S. adolescents aged 13–20 had dental coverage from either private (55.7 percent) or public (23.6 percent) sources. This represents a significant increase in coverage subsequent to enactment of the State Children’s Health Insurance Program (SCHIP), with public dental coverage increasing for eligible children and adolescents by 73 percent between 1996 and 2004 (from 12.0 to 20.7 percent). However, the disparity between services provided to medically insured and uninsured adolescents is typi- 1 Insurance status is defined as of the time of the survey. Public coverage includes Medicaid, the State Children’s Health Insurance Program (SCHIP), and other state coverage, while private coverage includes employer-sponsored and nongroup coverage.
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Adolescent Health Services: Missing Opportunities TABLE 6-1 Indicators of Access to Care Among Adolescents Aged 10–18 by Coverage Status Indicator of Access Adolescents with Public Coveragea Adolescents with Private Coverageb Uninsured Adolescents Percent Std. Error Percent Std. Error Percent Std. Error Failed to get needed medical care because of cost 2.6 0.3 1.1 0.1 13.3 0.8 Delayed getting medical care because of cost 4.1 0.4 2.4 0.2 17.2 0.9 Failed to get needed prescription drugs because of cost 4.3 0.5 2.1 0.2 11.2 1.1 No usual source of care 6.6 0.6 3.6 0.3 41.3 1.8 No physician visit in the past year 14.4 0.8 11.8 0.5 40.6 1.9 aIncludes Medicaid, State Children’s Health Insurance Program, and other state coverage. bIncludes employer-sponsored insurance and nongroup insurance. SOURCE: Tabulations from the 2004–2005 National Health Interview Survey.
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Adolescent Health Services: Missing Opportunities cally greater for dental care than for medical care because of the structure of dental coverage. Based on the National Survey of America’s Families, it is estimated that 42 percent of uninsured adolescents aged 11–17 failed to make recommended dental visits in a year, a rate three times higher than that for their privately insured counterparts. These uninsured adolescents were also 2.4 times more likely to miss recommended dental visits than medical health maintenance visits (Yu et al., 2002). At all ages, those with private health insurance coverage access more dental care than those who are uninsured, even in the absence of a dental benefit plan. The federal Medical Expenditure Panel Survey found that among those aged 13–20, those with no health insurance were half as likely to make a dental visit in a year as those with private coverage (27.5 percent compared with 57.5 percent) (Manski and Brown, 2007). In contrast, having publicly financed coverage is far less predictive of making a dental visit, as children and adolescents with public coverage were only modestly more likely to do so than those who were uninsured (34.1 percent compared with 27.5 percent). Having dental coverage further increases the likelihood of receiving dental care. Among children and adolescents under age 18, more than half (55.6 percent) of those with no insurance did not make a preventive dental visit in a year, while only half as many who had medical coverage (27.7 percent) and a third as many with both medical and dental coverage (19.9 percent) went without preventive dental care (Kenney, McFeeters, and Yee, 2005). Many adolescents fall through the cracks in the insurance system because of gaps in both public and private coverage (Collins et al., 2006, 2007). More than 4 million individuals aged 10–18 have no health insurance coverage whatsoever, according to recent census data (tabulations based on data from the 2005 Current Population Survey).2 It is striking to note that if those aged 19–24 are included, this figure rises to more than 12 million. Disparities in Coverage by Selected Population Characteristics For adolescents, medically uninsured rates are higher for those with lower income, for Hispanics (and to a lesser extent for African Americans) compared with whites, and for noncitizens compared with citizens (see Figure 6-1) (tabulations in this section are based on data from the 2005 Current Population Survey). Uninsured rates are also higher for those in 2 These estimates have been adjusted for the underreporting of public coverage on the Current Population Survey.
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Adolescent Health Services: Missing Opportunities FIGURE 6-1 Uninsured rates among adolescents aged 10–18 by race/ethnicity, income, and U.S. citizenship, 2004. Data reflect adjustments for the underreporting of public coverage. NOTE: FPL = federal poverty level. SOURCE: Tabulations based on data from the 2005 Annual Social and Economic Supplement to the Current Population Survey.
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Adolescent Health Services: Missing Opportunities health insurance units with nonworking or self-employed adults or only those employed by small firms.3 Not only do low-income adolescents have higher uninsured rates compared with higher-income adolescents, but almost half (44.4 percent) of all uninsured adolescents have family incomes below the federal poverty level. Uninsured adolescents are diverse in terms of their race/ethnicity: 40.1 percent are white, 17.0 percent are African American, 35.8 percent are Hispanic, and 7.0 percent are in the “other race” category. Despite having much higher uninsured rates, noncitizens constitute less than one-fifth (17.3 percent) of uninsured adolescents (tabulations from the 2005 Current Population Survey). Medically uninsured rates are substantially lower for adolescents in families that include at least one adult employed by a large firm (defined as more than 100 employees). For example, across the entire 10–18 age group, those in families with at least one adult working for a large firm were less than half as likely to be medically uninsured as those in families with all adults working for smaller firms—a differential driven by the much higher rate of employer-sponsored coverage in the large-firm category (tabulations from the 2005 Current Population Survey). Older adolescents (aged 19–24) who are full-time students are much less likely to lack insurance coverage than those in the same age group who are part-time students or are not students (tabulations from the 2005 Current Population Survey). This differential is likely to be driven by full-time students’ greater access to both insurance coverage provided through colleges and employer-sponsored coverage from their parents. Although fewer adolescents have dental than medical coverage, disparities in coverage by age, income, race, parental education, sex, and special-needs conditions are similar. In the aggregate, 22.1 percent of the population under age 17 is estimated to have no dental coverage based on the National Survey of Children’s Health. Highest rates of a lack of dental coverage are reported among children and adolescents who also lack medical coverage (79.3 percent), foreign-born Hispanics (66.8 percent), those who live in households in which the highest educational attainment is less than high school (36.0 percent), and those in poverty (27.8 percent) (Liu et al., 2007). Rates of a lack of dental coverage among adults are higher (34.2 percent, based on data from the Medical Expenditure Panel Survey) than those among the adolescent population, primarily because public dental coverage is generally unavailable to adults, yet these disparities 3 Health insurance units (HIUs) reflect the unit that would be used to determine eligibility for both private and public coverage. HIUs encompass the members of a nuclear family who could be considered eligible for a family health insurance policy. The terms “families” and “health insurance units” are used interchangeably in this chapter.
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Adolescent Health Services: Missing Opportunities persist (Manski and Brown, 2007). As evidence has grown that maternal oral health profoundly impacts children’s oral health and may affect birth outcomes as well, a number of states have recently added dental benefits to their adult Medicaid programs for pregnant women. Findings: More than 4 million adolescents aged 10–18 are medically uninsured. Uninsured rates are higher among the poor and near poor, racial and ethnic minorities, and noncitizens than among the general adolescent population. As is true for all Americans, medically uninsured adolescents are less likely to have a regular source of primary care and use medical and dental care less often compared with those who have insurance. Eligibility for Coverage for Adolescents Although those aged 19–24 lie outside the age range covered in this report, it is striking to note that eligibility for public coverage is lower for this group than for those aged 18 and under (Brindis, Morreale, and English, 2003; Cohen Ross, Cox, and Marks, 2007; Fox, Limb, and McManus, 2007b). Currently, the majority of states offer health and dental coverage under Medicaid and SCHIP for almost all children with family incomes below 200 percent of the federal poverty level (Cohen Ross, Cox, and Marks, 2007).4 In contrast, most individuals aged 19–24 qualify for public coverage only if they meet narrow categorical eligibility standards (e.g., pregnancy, disability, Temporary Assistance for Needy Families Program). While some states have extended Medicaid coverage to adolescents who are leaving the foster care system, many who leave foster care become uninsured (English, Morrreale, and Larsen, 2003; English, Stinnett, and Dunn-Georgiou, 2006). Similarly, a study of SCHIP enrollees in 10 states found that two-thirds of disenrollees aged 18 or older were uninsured 6 months after they disenrolled from the program, a much higher proportion than that found among younger disenrollees (Kenney et al., 2005). In addition, individuals aged 19–24 are less likely than those aged 10–18 to qualify for employer-based medical coverage (Collins et al., 2006). This is the case because of restrictions under private plans requiring that individuals over age 18 be full-time college students to qualify for employer- 4 As of July 2006, 41 states and the District of Columbia had income thresholds of 200 percent of the federal poverty level or above for citizen children and certain groups of immigrant children.
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Adolescent Health Services: Missing Opportunities based coverage through a parent, and because many in this age range who are employed are not offered employer-sponsored coverage (Clemans-Cope and Garrett, 2006). Moreover, the employment-based coverage that is available to those aged 19–24 may not be affordable (especially for those who are low-income), or for those in good health and lacking chronic health problems, it may not be perceived as providing benefits that outweigh the costs. For those who lack access to employer-sponsored insurance, finding affordable coverage in the nongroup insurance market may be difficult; this is particularly true for those who have health problems. Similarly, the nongroup dental insurance market offers plans that are typically limited in services, payment levels, or participating providers. The medically uninsured are concentrated at the upper end of the 19–24 age range, as fully 4.5 million individuals aged 22–24 and 3.6 million aged 19–21 lack coverage, compared with a total of 4.4 million aged 10–18 (tabulations in this section are based on data from the 2005 Annual Social and Economic Supplement to the Current Population Survey). Likewise, uninsured rates increase over this age range, with the largest jump—from 15.3 to 30.5 percent, an increase of about 100 percent—occurring between the 17–18 and 19–21 age groups. Uninsured rates reach 36.6 percent among those aged 22–24. These high uninsured rates among those aged 19–24 are a function of lower reliance on both public and private coverage—29.1 percent of those aged 10–13 have Medicaid/SCHIP coverage and 56.6 percent employer-sponsored insurance, compared with 9.5 percent and 42.2 percent, respectively, of those aged 22–24. As indicated above, young adults are much less likely than adolescents aged 18 and under to qualify for both public and private coverage. Addressing the Problem of Medically Uninsured Adolescents Many poor adolescents, particularly those between the ages of 10 and 18, are medically uninsured despite being eligible for Medicaid or SCHIP coverage. Tabulations in this section are based on data from the 2005 Annual Social and Economic Supplement to the Current Population Survey and Urban Institute estimates of eligibility for Medicaid and SCHIP. As described in more detail below, knowledge barriers and problems associated with the Medicaid and SCHIP enrollment processes appear to deter participation in public programs among these uninsured adolescents. Overall, 65 percent of all uninsured adolescents (aged 10–18)—more than 2.8 million individuals—appear to be eligible for Medicaid or SCHIP coverage. More than 80 percent of uninsured adolescents living below 200 percent of the federal poverty level are eligible. As adolescents reach age 19, their eligibility for Medicaid/SCHIP coverage decreases significantly. Eligibility overall is much higher among younger relative to older adolescents who are un-
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Adolescent Health Services: Missing Opportunities insured: eligibility rates are 65 percent, 62 percent, and 67 percent among adolescents aged 10–13, 14–16, and 17–18, respectively, compared with 20 and 12 percent, respectively, among those aged 19–21 and 22–24. Enrollment in public coverage appears to improve access to care relative to being uninsured for adolescents aged 18 and under (Dick et al., 2004; Kenney, 2007; Klein et al., 2007). In the three studies referenced here and previously described dental studies, enrollment in public coverage increased the likelihood of having a usual source of care and of receiving preventive care. In addition, Klein and colleagues (2007) found that the extent to which confidential care and preventive counseling were provided to adolescents increased following enrollment in public coverage. Both they and Kenney (2007) also found that enrollment in public coverage reduced unmet health care needs among adolescents. Together, Medicaid and SCHIP could address nearly two-thirds of the uninsured problem among those aged 10–18 and 84 percent of the problem among those in low-income families in this age group (defined as having an income below 200 percent of the federal poverty level). The bulk of the remaining low-income uninsured adolescents aged 10–18 who do not qualify for Medicaid or SCHIP coverage are legal immigrants who are ineligible for coverage because they have not been in the country for more than 5 years; are undocumented immigrants and qualify only for emergency Medicaid, which is very limited in scope; live in the nine states that have income thresholds below 200 percent of the federal poverty level; or do not live in selected California counties or states that have targeted insurance coverage initiatives with state or local funds. Access to employer-sponsored coverage is also very limited among noncitizen children (Ku and Matani, 2001; Ku and Waidmann, 2003; Schur and Feldman, 2001). Therefore, reducing uninsurance among noncitizen adolescents will likely require expanding Medicaid and SCHIP coverage to more immigrant children. More than 80 percent of all low-income parents say they would enroll their uninsured adolescents aged 13–17 in Medicaid/SCHIP if told the adolescents were eligible (see Figure 6-2). Therefore, policies aimed at increasing awareness of Medicaid and SCHIP among families whose adolescents could qualify for public coverage hold promise for being successful (Kenney, Haley, and Tebay, 2004). However, just 43 percent of parents of low-income uninsured adolescents believed their adolescents were eligible for coverage, a much lower proportion than found for younger children (Kenney, Haley, and Tebay, 2004). Moreover, 40 percent believed that the Medicaid and SCHIP application processes were easy, a figure again lower than that for parents of younger children (Kenney, Haley, and Tebay, 2004). Thus, increasing participation in Medicaid/SCHIP among adolescents may require targeted outreach and enrollment efforts aimed specifically at families with adolescents.
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Adolescent Health Services: Missing Opportunities FIGURE 6-2 Awareness and perceptions of Medicaid/State Children’s Health Insurance Program among low-income families with uninsured adolescents aged 13–17. SOURCES: Tabulations are based on the Centers for Disease Control and Prevention, National Center for Health Statistics, State and Local Area Integrated Telephone Survey, National Survey of Children with Special Health Care Needs, 2001. Although those aged 19–24 are beyond the primary focus of this report, it is useful to compare their uninsured problem with that of younger adolescents. Only a small fraction of the uninsured in this older age group—just 20 percent of those aged 19–21 and 12 percent of those aged 22–24—appear to be eligible for public coverage. Moreover, among the uninsured living below the poverty line aged 19–21 and 22–24, respectively, just 36 and 23 percent meet the requirements for Medicaid/SCHIP eligibility. In addition, very few uninsured in these age groups with incomes between 100 and 200 percent of the federal poverty level are eligible for Medicaid/SCHIP coverage. Therefore, substantially reducing uninsurance among those aged 19–24 will require more than increasing participation in existing Medicaid and SCHIP programs. One approach would be to require that employer-based insurance plans cover dependents up to age 23 or higher. For example, new laws that became effective in 2006 in New Jersey and Colorado require group health plans to cover more dependents up to ages 30 and age 25, respectively (Collins et al., 2006). A number of private health insurance
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Adolescent Health Services: Missing Opportunities BOX 6-1 Overview of Financing of Mental Health and Substance Abuse Treatment Services For several decades in the twentieth century, mental health specialty services were funded and organized by public mental health authorities predominantly at the state level. Even as general medical care became increasingly the domain of commercial insurance and Medicaid/Medicare in the second half of the century, the specialty mental health care system was strongly influenced by the public mental health system. However, the last 30 years saw mental health advocates push successfully for access to Social Security Income enrollment, expanded Medicaid benefits, housing support, and other federal and state social insurance programs for persons with mental disorders. These programs greatly increased the integration of persons with these disorders into services and the community, but also made policy and financing for mental health services a small component of much larger programs, such as Medicaid. Today, although mental health services across all programs are funded at a higher level than at any time in the past, mental health advocates are increasingly less able to influence policy with the needs of adolescents affected by mental disorders in mind because of the size and scope of these larger programs. This trend is likely to continue as the numbers of public mental health institutions and spending on public mental health specialty services diminish (Nutt and Hogan, 2005). The affordability of mental health care for adolescents is modulated by the complex patchwork of public and private payors that constitute the putative health care system in the United States. The resulting inequities and inadequacies in health care delivery for children and families generally and adolescents in particular are extensively documented. These inequities and inadequacies are exacerbated for adolescents with mental disorders seeking care because of higher levels of patient cost sharing for such care, more limited benefits, greater demand for health care management, and bias against adolescents with mental disorders as compared with those with other disorders. Although these factors are historical remnants of the placement of adolescents with mental disorders in public institutions, their persistence today means there are considerable barriers to affordable mental health care for many adolescents. For example, out-of-pocket costs for health care for adolescents with common mental disorders are higher than for those with other common medical problems. A variety of efforts over the past two decades have been aimed at lowering cost barriers to mental health services for both adolescents and others with mental disorders. These include expansions of adolescents’ eligibility for Medicaid and the State Children’s Health Insurance Program (SCHIP) to levels equal to those for younger children; Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) screening recommendations for Medicaid-eligible adolescents; legislative parity initiatives for non–Employee Retirement Income Security Act (ERISA) commercial insurance plans in several states; and the elimination of custody relinquishment in some states for Medicaid reimbursement in intensive settings. In addition, the use of Social Security Income eligibility for Medicaid enrollment for many severely affected adolescents has expanded. Recently, some states have improved Medicaid reimbursement for primary care mental health services. Unfortunately, many financial barriers to effective mental health care remain.
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Adolescent Health Services: Missing Opportunities might be available on a case-by-case basis in other states). Residential treatment would be covered in about three-quarters of states for both mental heath and substance abuse conditions. Two states, however, would impose an annual cap of $6,000 or $8,000 on substance abuse treatment but not on mental health care. In addition, several states would impose a limit of 30 visits or 30 days of inpatient care for mental health and substance abuse services combined, further limiting coverage for adolescents with co-occurring conditions (Fox, Levtov, and McManus, 2003). The MCHPRC study found that cost sharing for some types of mental health and substance abuse treatment services was required in most of the 36 separate SCHIP programs, but was usually nominal. About a third required cost sharing for outpatient services—usually a $5 copayment—but one state required coinsurance amounting to 50 percent of the service cost. About a quarter of states required cost sharing for inpatient care, with $25 being the average charge, but two states required significant coinsurance (Fox, Levtov, and McManus, 2003). Private insurers Almost all privately insured adolescents appear to have coverage for mental health services, while a somewhat smaller proportion have coverage for substance abuse treatment, although typically with limits on outpatient visits or inpatient days. According to the 2006 Kaiser/HRET Survey, it is likely that 97 percent of adolescents insured under employer-sponsored plans have mental health benefits, but that as many as two-thirds face an annual maximum of 30 outpatient visits and 30 or fewer inpatient days (The Kaiser Family Foundation and Health Research and Educational Trust, 2006). In fact, more than a third of plans limit coverage to 20 or fewer visits, and 10 percent limit coverage to 10 or fewer inpatient days (The Kaiser Family Foundation and Health Research and Educational Trust, 2006). An earlier study found that benefit limits imposed under behavioral health plans are more likely to affect children and adolescents than adults, particularly for those with chronic mood disorders or psychoses (Peele, Lave, and Kelleher, 2002). With respect to substance abuse treatment, a survey of employees’ benefits in small, medium, and large firms found that in 2003, almost 90 percent of adolescents covered under employer-based plans would have had coverage for outpatient treatment and almost 95 percent for inpatient treatment, but always with visit or day limits and sometimes with inpatient benefits limited to detoxification (U.S. Bureau of Labor Statistics, 2005). The only information on benefit limits is from the earlier MCHPRC study, which found that 20 outpatient visits and 30 inpatient days were the most common limits (U.S. Bureau of Labor Statistics, 2005). The MCHPRC study also found that benefit limits were often combined for mental health and substance abuse treatment services. Two-thirds
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Adolescent Health Services: Missing Opportunities of plans imposed coverage exclusions for conditions such as personality disorders, conduct disorders, behavior disorders, attention-deficit hyperactivity disorder, impulse control disorder, chronic conditions, self-inflicted injuries, emotional disorders, and eating disorders, as well as conditions that do not improve within a short period of time. In addition, more than half of plans excluded specific types of treatment, such as family counseling, services not for evaluation and crisis intervention, psychological testing, and behavior modification (U.S. Bureau of Labor Statistics, 2005). Dental Services Medicaid Comprehensive dental services, including regular dental examinations and necessary services related to the relief of pain, restoration of teeth, and maintenance of dental health, are required services for all adolescents up to age 21 through the EPSDT benefit. Upon turning 21, dental coverage for Medicaid beneficiaries is provided by their state Medicaid plan as an optional service. Currently only 9 states provide coverage for reasonably comprehensive preventive and restorative dental services for those over age 21, while 15 states provide coverage for only emergency relief of pain and infection, and 7 have no dental Medicaid benefit of any kind for those over age 21 (Edelstein, Schneider, and Laughlin, 2007). Copayments for covered adult dental services are required in 25 states, but the specific amounts are not available (Kaiser Commission on Medicaid and the Uninsured, 2004a). SCHIP States are not federally required to cover dental services under separate SCHIP programs. Nonetheless, all states but one currently include some level of dental coverage in their state plans for children and adolescents. Because dental coverage is optional, there is no consistent access to dental services in some states through SCHIP. For example, Colorado and Delaware did not include a dental benefit in their plans until years after establishing medical coverage programs; Texas and Utah dropped their dental coverage only to reinstate it later; Georgia and other states have intermittently considered eliminating dental coverage; and Tennessee provides medical but not dental coverage to adolescents from families with income levels targeted by the SCHIP program. In addition, states vary considerably in the extent of dental coverage offered because the original SCHIP legislation does not define dental coverage. SCHIP plans therefore vary considerably in their dental service limits, including treatment frequencies, materials, procedures, and ages. They also vary considerably in the extent of coverage. Six states (Colorado, Florida, Michigan, Montana, New York, and Texas) have imposed caps of less than $1,000 per year on dental benefits, thereby significantly limiting the utility of this benefit for
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Adolescent Health Services: Missing Opportunities many adolescents. Others have imposed higher dollar caps and copayment requirements that impede access to dental services for adolescents from targeted working-poor families. The American Dental Association (Edelstein, Schneider, and Laughlin, 2007) reports that 19 states have elected to cover dental services for all SCHIP beneficiaries through separate SCHIP plans, 8 through combination separate SCHIP and Medicaid plans, and 21 through Medicaid expansion or expansion look-alike designs. Medicaid expansion states are required to provide comprehensive EPSDT dental benefits to adolescents through age 19. All 27 states with full or partial separate dental plans cover basic diagnostic, preventive, and reparative services with minor exceptions, but a high proportion of these states do not cover prosthodontic (6 states), periodontic (7 states), and orthodontic services (14 states). Private insurers About half of privately insured adolescents are likely to have coverage for dental services through employer-sponsored plans (The Kaiser Family Foundation and Health Research and Educational Trust, 2006; U.S. Bureau of Labor Statistics, 2006). Unfortunately, the scope of dental benefits is not documented in either of the referenced surveys, nor is cost-sharing information available. Cost Sharing and Provider Participation Out-of-pocket cost sharing, particularly in private plans, may deter individuals and families from seeking needed care. When families face high deductibles and copayments, they may be reluctant to attend to ongoing health care needs, leading to an increase in unmet needs (Buntin et al., 2005; Newhouse, 2004; Newhouse and the Insurance Experiment Group, 1993). Over the last decade, deductibles and out-of-pocket cost-sharing requirements have increased in private plans (Glied and Remler, 2005; Mercer Health and Benefits, 2007). Between 2003 and 2005, the share of firms that offered employees a high-deductible health insurance plan rose from 5 to 20 percent (The Kaiser Family Foundation and Health Research and Educational Trust, 2005). Historically, public policies have been designed to keep out-of-pocket cost sharing in public programs low, although higher cost sharing is permitted under SCHIP than under Medicaid, and the Deficit Reduction Act of 2005 permitted more cost sharing in Medicaid. To date, no published study has examined the effects on adolescents of different copayment schedules in public programs. In addition, having benefits with low cost sharing on paper does not always translate into access to services because providers may be unwilling to offer services under that type of insurance coverage. This is a particular
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Adolescent Health Services: Missing Opportunities concern for Medicaid programs, whose provider reimbursement levels are well below market rates in many service areas (Tang, 2001; Zuckerman et al., 2004). Research suggests that physicians’ participation in Medicaid and SCHIP is higher in states that pay them more (Berman et al., 2002). Just two-thirds of all physicians have no limits on the number of Medicaid and SCHIP patients they will see (Tang, Yudkoswky, and Davis, 2003), and Medicaid patients have become increasingly concentrated at fewer and fewer physicians’ offices (Cunningham and May, 2006). In addition, despite the availability of relatively generous mental health and substance abuse benefits for publicly insured adolescents, an abundant literature documents significant access difficulties due to multiple factors, including shortages and maldistribution of providers (Kim, 2003; Koppelman, 2004; New Freedom Commission on Mental Health, 2003; Thomas and Holzer, 1999; U.S. Department of Health and Human Services, 1999), waiting lists for services, and lack of transportation (Semansky and Koyanagi, 2004). Separate capitation arrangements for behavioral health services may present an additional barrier to the receipt of needed services. A number of studies have found that adolescents enrolled in behavioral health carve-out plans receive fewer inpatient services but more residential, outpatient, and other community-based services; these studies did not assess whether this substitution is appropriate to meet the adolescents’ needs (Burns et al., 1999; Libby et al., 2002; Stroul et al., 1998). Investment in Preventive and Chronic Care Services Prevention and sustained, effective treatment for chronic physical, dental, and mental health problems were identified as key elements of health services for adolescents earlier in this report. However, the current health care financing system, with its fragmented coverage for the nonelderly, does not offer strong incentives to invest in prevention or to treat chronic health problems adequately. Individuals rarely maintain the same insurance coverage over their life span (Herring, 2006). Private insurance plans, which remain the norm, are built around employer-based coverage provided on a voluntary basis, which is not necessarily affordable or even available. Eligibility for public coverage varies across states and with age, family circumstances and income, and health status (Centers for Medicaid and Medicare Services, 2005a,b). Thus, individuals’ insurance coverage changes when they experience any of a number different events, such as a birthday; a job change for themselves, their spouse, or a parent; marriage; divorce; disability; or a change in family income. Since individuals switch insurance coverage over the course of their lives, any investments made by a given insurer that yield health care savings down the road will not necessarily result in a payoff to that insurer.
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Adolescent Health Services: Missing Opportunities In addition, some preventive investments may not yield health care savings but may instead produce savings in other areas, such as the criminal justice system. Given these externalities, the current health care financing system leads to lower investments in prevention than would occur under alternative financing arrangements. For Medicaid-insured adolescents, reimbursement policies are not structured to support the delivery of comprehensive preventive services. Only 33 states, for example, pay for annual preventive visits for adolescents (Fox, Limb, and McManus, 2007a). Moreover, risk reduction counseling services to address such issues as family problems, sexual practices and contraceptives, and injury prevention are reimbursed in only about half of states (Fox, Limb, and McManus, 2007a). Restrictions on billing for two services on the same day are also an impediment to the delivery of comprehensive preventive services. While a billing mechanism does exist that allows a provider to be reimbursed for a well-adolescent visit and the provision of additional health counseling, only 7 Medicaid agencies expressly allow the practice, while 18 explicitly deny it (Fox, Limb, and McManus, 2007a). Insurer Policies on Confidential Adolescent Health Services Payment policies utilized by third-party payors compromise the delivery of confidential services to adolescents, even in states that have laws allowing minors to consent on their own to certain sensitive services. The managed care practice of sending documents to the primary insured party (usually a parent) undermines the ability of providers to deliver truly confidential services to adolescents and has a particularly strong impact on adolescents’ receipt of behavioral and sexual and reproductive health services (Gudeman, 2003). These documents, known as explanations of benefits (EOBs), usually detail the services delivered and any outstanding cost-sharing payment that is owed. This practice is universal among private payors and is also used by managed care companies delivering services to adolescents enrolled in Medicaid and SCHIP, even in the absence of cost-sharing requirements, as no state has included a prohibition against sending EOBs in its managed care contracts (Brindis et al., 1999). Finding: Having health insurance does not ensure adolescents’ access to affordable, high-quality services given problems associated with high out-of-pocket cost-sharing requirements, limitations in benefit packages, and low provider reimbursement levels. For example, the current system for financing health insurance coverage leads to underinvestments in disease prevention and treatment in some areas that are particularly problematic for adolescents.
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Adolescent Health Services: Missing Opportunities SUMMARY Approximately one in nine adolescents (11.5 percent) aged 10–18 lack insurance coverage. Many adolescents are uninsured despite being eligible for Medicaid or SCHIP coverage. Those who are without coverage are less likely to have a usual source of care and to receive health services and more likely to have unmet health needs. However, adolescents who have coverage experience difficulty gaining access to the services they need because of a combination of limits in benefits packages, cost-sharing requirements, lack of access to providers, and unavailability of confidential health services. These problems are particularly acute with respect to preventive, sexual and reproductive health, mental health and substance abuse treatment, and dental services. REFERENCES Berman, S., Dolins, J., Tang, S., and Yudkowsky, B. (2002). Factors that influence the willingness of private primary care pediatricians to accept more Medicaid patients. Pediatrics, 110, 239–248. Bondi, M. A., Harris, J. R., Atkens, D., French, M. E., and Umland, B. (2006). Employer coverage of clinical preventive services in the United States. American Journal of Health Promotion, 20, 214–222. Brindis, C., Kirkpatrick, R., Macdonald, T., VanLandeghem, K., and Lee, S. (1999). Adolescents and the State Children’s Health Insurance Program: Healthy Options for Meeting the Needs of Adolescents. Washington, DC: Association of Maternal and Child Health Programs and San Francisco: University of California, Policy Information and Analysis Center for Middle Childhood and Adolescence and National Adolescent Health Information Center. Brindis, C. D., Morreale, M. C., and English A. (2003). The unique health care needs of adolescents. Future of Children, 13, 117–135. Brindis, C. D., Hair, E. C., Cochran, S., Cleveland, K., Valderrama, L. T., and Park, M. J. (2007). Increasing access to program information: A strategy for improving adolescent health. Maternal and Child Health Journal, 11, 27–35. Buntin, M. B., Damberg, C., Haviland, A., Lurie, N., Kapur, K., and Marquis, M. S. (2005). Consumer-Directed Health Plans: Implications for Health Care Quality and Cost. Report Prepared for the California HealthCare Foundation. Santa Monica: RAND. Burns, B. J., Teagle, S. E., Schwartz, M., Angold, A., and Holtzman, A. (1999). Managed behavioral health care: A Medicaid carve-out for youth. Health Affairs, 18, 214–225. Callahan, S. T., and Cooper, W. O. (2005). Uninsurance and health care among young adults in the United States. Pediatrics, 116, 88–95. Centers for Disease Control and Prevention, National Center for Health Statistics. (2001). State and Local Area Integrated Telephone Survey, National Survey of Children with Special Health Care Needs, 2001. Available: http://www.cdc.gov/nchs/data/series/sr_02/sr02_136.pdf [August 15, 2008]. Centers for Medicaid and Medicare Services. (2005a). Low-Cost Health Insurance for Families and Children. Insure Kids Now! Available: http://www.cms.hhs.gov/LowCostHealthInsFamChild/02_InsureKidsNow.asp#TopOfPage [June 5, 2007]. Centers for Medicaid and Medicare Services. (2005b). Medicaid Eligibility. Available: http://www.cms.hhs.gov/MedicaidEligibility/ [June 5, 2007].
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