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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