5
Health and Health Care

Adolescent health has become an identified concern for policy makers and researchers only in the past decade (U.S. Office of Technology Assessment, 1991a). This attention stems from changing conceptions of illness and disease prevention and awareness that adolescent health issues are often different from those of children or adults. It also stems from the recognition that conventional concepts of medical care, rooted in the biological determinants of disease, are not directly applicable to the serious health problems manifested by adolescents, many of which are related to patterns of behavior adopted by adolescents in response to their environments. There is also concern that the health status of adolescents has failed to improve over the past two decades. Since the early 1980s, for example, adolescent deaths from homicide, suicide, and HIV/AIDS have increased. Furthermore, the rates of teenage pregnancy, sexually transmitted diseases, and drug use have either increased or remained at high levels relative to that observed in other countries. Finally, it has become apparent that many adolescents who have one type of problem often have others; approximately 25 percent are considered at high risk for a poor transition into adulthood (Osgood, 1989; Millstein et al., 1992; Dryfoos, 1990).

These findings have led to a broad consensus among health care workers and researchers that most of the salient causes of adolescent mortality and morbidity are preventable. For example, poverty is consistently the strongest sociodemographic predictor of



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Losing Generations: Adolescents in High-Risk Settings 5 Health and Health Care Adolescent health has become an identified concern for policy makers and researchers only in the past decade (U.S. Office of Technology Assessment, 1991a). This attention stems from changing conceptions of illness and disease prevention and awareness that adolescent health issues are often different from those of children or adults. It also stems from the recognition that conventional concepts of medical care, rooted in the biological determinants of disease, are not directly applicable to the serious health problems manifested by adolescents, many of which are related to patterns of behavior adopted by adolescents in response to their environments. There is also concern that the health status of adolescents has failed to improve over the past two decades. Since the early 1980s, for example, adolescent deaths from homicide, suicide, and HIV/AIDS have increased. Furthermore, the rates of teenage pregnancy, sexually transmitted diseases, and drug use have either increased or remained at high levels relative to that observed in other countries. Finally, it has become apparent that many adolescents who have one type of problem often have others; approximately 25 percent are considered at high risk for a poor transition into adulthood (Osgood, 1989; Millstein et al., 1992; Dryfoos, 1990). These findings have led to a broad consensus among health care workers and researchers that most of the salient causes of adolescent mortality and morbidity are preventable. For example, poverty is consistently the strongest sociodemographic predictor of

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Losing Generations: Adolescents in High-Risk Settings poor health (Gans et al., 1990), but poverty can be reduced by employment or income transfers. Similarly, using seat belts can reduce the harm of accidents, and using condoms can prevent pregnancy as well as sexually transmitted diseases. Moreover, evaluations of health service programs indicates that they can reduce the frequency of many conditions and ameliorate the severity of others, even when social factors weigh heavily in the genesis of the conditions (Starfield, 1985). The extent of overlap and preventability of many types of health problems provides a focus for adolescent health care that is consistent with the World Health Organization (WHO) definition of health as "the complete physical, mental, and social well-being" of the individual (Health Promotion, 1987). Indeed, one recent study concludes (U.S. Office of Technology Assessment, 1991a:4): This broader view of health—emphasizing mental and social, as well as physical, aspects and a sense of well-being as well as the absence of problems—can be said to fit the period of adolescence much better than does a narrow focus on the absence of physical health problems. HEALTH STATUS OF ADOLESCENTS In many respects, the United States has made progress in ensuring good physical health for its citizens. People in all groups (except black males) live about 7 years longer than they did in 1967. However, violence and intentional injury remain serious health problems in this country. Compared with 30 other industrialized countries, the United States has the highest rates of sexual assault and assault with force, and is third in homicide. Concurrently, the United States is becoming a "melancholy" society: since the early 1900s, successive birth cohorts have shown increased rates and earlier onset of depression and suicide (van Dijk et al., 1990; Murphy and Wetzel, 1980). These trends are particularly pronounced among adolescents (see Table 5-1). Fifty years ago, most adolescents died from natural causes, but there has since been a steady decrease in adolescent deaths by cancer, heart disease, and cardiovascular disease. Unfortunately, those declines have been offset in part by steady increases in death through accidental and intentional injuries (including suicide), which now account for 75 percent of the 20,000 adolescent deaths each year. Indeed, mortality rates for adolescents have increased since the mid-1980s. And, because of high injury and violence rates, youth in the United States are far more likely to die during adolescence than their age-mates in other

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Losing Generations: Adolescents in High-Risk Settings TABLE 5-1 Deaths of People Aged 15 to 24, by Age and Cause of Death, 1965-1988 (number per 100,000) Cause of Death 1965 1980 1988 15 to 19 years old All causes 95.1 97.9 88.0 Motor vehicle accidents 40.2 43.0 37.3 All other accidents 16.5 14.9 9.4 Suicide 4.0 8.5 11.3 Males, white 6.3 15.0 19.6 Females, white 1.8 3.3 4.8 Males, all other races 5.2 7.5 11.0 Females, all other races 2.4 1.8 2.6 Homicide 4.3 10.6 11.7 Males, white 3.0 10.9 8.1 Females, white 1.3 3.9 3.0 Males, all other races 30.6 43.3 64.4 Females, all other races 7.1 10.1 10.2 Cancer 7.6 5.4 4.4 Heart disease 5.3 2.3 2.2 Pneumonia/influenza 2.1 0.6 0.5 20 to 24 years old All causes 127.3 132.7 115.4 Motor vehicle accidents 49.3 46.8 39.7 All other accidents 18.7 18.8 12.4 Suicide 8.9 16.1 15.0 Males, white 13.9 27.8 27.0 Females, white 4.3 5.9 4.4 Males, all other races 13.1 20.9 20.0 Females, all other races 4.0 3.6 3.0 Homicide 10.0 20.6 19.0 Males, white 7.4 19.9 14.8 Females, white 2.3 5.4 4.7 Males, all other races 80.5 109.4 105.6 Females, all other races 17.3 23.3 19.7 Cancer 9.0 7.2 5.7 Heart disease 9.3 3.5 3.6 Pneumonia/influenza 2.3 1.0 0.9   SOURCE: Office of Education Research and Improvement (1991).

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Losing Generations: Adolescents in High-Risk Settings industrialized countries (Irwin et al., 1991; Fingerhut and Kleinman, 1989; Eisenberg, 1984). Adolescent suicide rates have nearly tripled since 1960 and are now second only to those for people over age 65. More than 5,000 adolescents kill themselves each year, and an estimated 400,000 attempt suicide. Males are disproportionately represented in the first group and females in the second. Teenage deaths by violence are directly related to economic and social conditions in low-income neighborhoods (see Chapter 8) and to the availability of guns in American society. Age-adjusted rates of suicide by means of firearms increased 45 percent in a decade, while the rate for other means remained the same (Eisenberg, 1984). In 1987 firearms accounted for 68 percent of all adolescents who were murdered and 83 percent of all suicides. The rise in teenage homicide and suicide suggests an increasingly high level of hopelessness, grief, and anger among adolescents. Another indication of such feelings is the rise in the proportion of children and adolescents receiving professional psychological assistance, which increased by 50 percent from 1981 to 1988 (Zill and Schoenbom, 1990). Between 15 and 19 percent of all children and adolescents suffer an emotional or psychiatric problem that warrants mental health treatment, and rates may have increased in recent years to between 17 and 22 percent (Institute of Medicine, 1989; Tuma, 1989). The occurrence of such a problem increases with age and varies by gender: for adolescents aged 12-17, for example, 20.4 percent of older adolescent males and 16.5 of their female counterparts have experienced an emotional or behavioral disorder (Zill and Schoenbom, 1990). The Institute of Medicine (1989:33) notes: [The] fact that so many children are affected should not suggest that these mental disorders are trivial or transient; on the contrary, childhood mental disorders are serious, persistent, and lead to suffering for the children and their families. Over the past decade, drug, alcohol, and cigarette use and unprotected sexual intercourse have come to be seen as significant health problems. One-third of all high school seniors report having drunk at least five drinks in a row at least once during a 2-week period, 17 percent report monthly use of marijuana, and about 19 percent smoke cigarettes on a daily basis (Bachman et al., 1991; National Institute on Drug Abuse, 1990). Among young women aged 15-17, the proportion who are sexually active has risen steadily over the past 20 years and was 38 percent in 1988. Boys at all ages report having sexual intercourse more frequently

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Losing Generations: Adolescents in High-Risk Settings than girls and at an earlier age. Contraceptive use, especially use of condoms, seems to be increasing, but about one-half of sexually active teenagers have unprotected sexual intercourse. About 2.5 million adolescents contract a sexually transmitted disease each year, and prevalence rates have increased over the past decade—especially for syphilis—to levels that were last seen in the 1940s (Sonenstein et al., 1990; Irwin et al., 1991). Unprotected sexual intercourse also contributes significantly to the risk of AIDS. AIDS is the fastest-growing cause of death among adolescents and young adults: within 5 years it is projected to be the leading cause of death among men aged 25-44. Given the time lag between viral infection and diagnosis, the number of undiagnosed cases of HIV infection among 13- to 29-year-olds is approximately 4.5 times greater than the total number of reported cases (about 8,000 as of April 1991). Those most at risk are runaways, youths engaged in prostitution, incarcerated youths, youths with homosexual experiences, and intravenous drug users. However, the spread of the epidemic makes such risk factors increasingly less useful in predicting individual or community risk (Joseph, 1992). THE HEALTH CARE SYSTEM AND ADOLESCENT HEALTH The provision of health care services to adolescents is the result of four intertwined characteristics of the structure of the U.S. health system. First is the medical model of care: that is, adolescent health is the domain of physicians and other medical professionals operating out of hospitals, clinics, and offices. Second, many if not most adolescents lack a consistent source of basic care over time. Third is the tangle of health insurance arrangements that define who can afford care and what services are eligible for reimbursement. Fourth, a large majority of adolescents have no financial access to care independent of their family, and access to appropriate service remains a large barrier; however, adolescents' health needs may sometimes be best addressed independently, outside the context of their families (U.S. Office of Technology Assistance, 1991a). Another important characteristic of the U.S. health system is that it is becoming more specialty-oriented. The proportion of young physicians who are choosing to train in a specialty rather than in primary care is increasing, and the availability of primary care physicians to the population is declining (Starfield, 1992).

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Losing Generations: Adolescents in High-Risk Settings The dearth of primary care is particularly problematic for children and youth, and especially for teenagers, since their major problems are not in the realm of medical or surgical subspecialties. Adolescents have a special need for the readily available, first-contact care that is the hallmark of primary care. Four other features of primary care are also urgently needed by adolescents (Starfield, 1992): Comprehensiveness of care, which involves a broad range of services, is critical; the social as well as biological components of their problems require multidisciplinary approaches. A long-term perspective on care is especially important for adolescents because many of their problems are not amenable to prevention, diagnosis, and management in only a few visits. Consistent provision of services over time by professionals who know the adolescent also fosters a trusting relationship, so that adolescents feel comfortable in seeking advice for incipient problems, presenting their existing problems, and accepting care and advice about the prevention and management of problems. Coordinated care is needed to integrate all aspects of services, including those that have to be provided by various specialists and other health professionals, into a person-centered system is also essential. The services that do exist for adolescents are fragmented and oriented toward specific problems rather than toward the constellations of problems that characterize adolescents. Existing services for substance abuse, mental health, trauma (e.g., emergency care), and reproductive and maternal health have developed largely in isolation from each other. In fact, the entire field of adolescent heath is new; the current U.S. health care system does not yet have a strategy for dealing with adolescents or for dealing with the broad concept of health embodied in the WHO definitions. Evolution of Adolescent Health Care The medical community became aware of the special health needs of adolescents only very recently. Most research on adolescent health during the first half of the twentieth century was concerned with the effects of various infectious diseases (Gallagher, 1982). Subsequently, conceptions of illness broadened, but adolescent health problems were still viewed in a biomedical context, as distinct disease entities, and psychosocial disorders, such as truancy, teenage pregnancy, and suicide, were seen as social deviancy. The first real professional attention came in the early

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Losing Generations: Adolescents in High-Risk Settings 1940s, when the morbidity and mortality burden of infectious diseases had diminished and other types of health problems were taking their place. However, the first textbook of adolescent medicine was not published until 1960 (Gallagher, 1960). And a major pediatric text published in 1975 reflected the medical community's neglect of the totality of adolescent health needs: sections on adolescent health included only growth and development, sexual maturation, nutrition, and psychological development rooted in Freudian theory (Vaughan et al., 1975). The American Medical Association (AMA) officially recognized adolescent medicine as a subspecialty in the 1970s, and the first subspecialty examination will be administered in 1994 for board-certified pediatricians and internists who aspire to certification in adolescent medicine. By the early 1990s the concept of adolescent health had become broader. Indeed, almost all aspects of adolescent development can now be viewed within the purview of ''health." For example, The Health of Adolescents, a text sponsored by the AMA, has chapters on substance abuse, sexually transmitted diseases, pregnancy and its outcomes, chronic illness and disability, injuries, disorders of self-image, depression, suicide, and maltreatment of adolescents (Hendee, 1991). Other recent works add delinquency and school failure to the list of health-related problems (Dryfoos, 1990; Strasburger and Greydanus, 1990). A major review by the U.S. Office of Technology Assessment (1991a) also reviewed data on family problems, nutrition and fitness problems, parenting, mental health, and homelessness. Two comprehensive textbooks on adolescent health published in 1992 provide authoritative surveys of the field (McAnarney et al., 1992; Friedman et al., 1992). By 1980 there were 35 fellowship training programs for adolescent medicine, 9 of which were federally funded; there are currently 44 such programs, 6 of which are federally supported. The number of physicians trained in adolescent medicine remains very small. It is estimated that there are about seven adolescent medicine specialists per 100,000 individuals between 14 and 20 years old. This small number of specialists is not even adequate to provide backup for the referrals and consultations made by a much larger number of primary care providers who are not trained in adolescent medicine (Starfield, 1992). Health Services Organization and Delivery Insufficient training of practitioners is a major barrier to managing adolescent health problems (Blum, 1987). Physicians often fail to recognize patients' health problems and are much more

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Losing Generations: Adolescents in High-Risk Settings likely to respond to physical symptoms than to psychosocial ones, even when the latter reflect serious psychosocial morbidity (see, e.g., Starfield and Borkowf, 1969). Another barrier is the general tendency of medical education to stress the diagnosis and management of problems rather than their prevention. Since adolescents comprise a small percentage of the practices of most physicians, there is little opportunity to gain on-the-job experience in dealing with adolescent concerns. Rates of visits to office-based physicians are 1.7 and 0.9 visits per person per year for white and black adolescents, respectively, compared with 2.7 visits per year for the population as a whole (Blum, 1990). These rates remained unchanged between 1980 and 1985 (DuRant, 1991). In fact, teenagers are less likely to have a regular source of care than are younger children (Blum, 1988). Among office-based physicians, teenagers have most of their contacts with general practitioners, family physicians, or pediatricians. The remainder, about 45 percent of all visits, are distributed among a variety of other specialists, including obstetricians and gynecologists, orthopedic surgeons, dermatologists, internists, ophthalmologists, and general surgeons. Among young adolescents aged 10-14, about one-third of visits are to family physicians and one-third to pediatricians. For older adolescents (aged 15-19), family practitioners account for 35 percent of visits and pediatricians for only 8 percent; but obstetricians and gynecologists receive more visits than pediatricians, 12 and 15 percent, respectively (Nelson, 1991). The extent to which these specialists are equipped for or interested in dealing with the full constellation of adolescent problems is unknown, but it is likely to be minimal. (Similar data are not available for adolescents who do not receive their care from office-based practitioners.) What is clear, however, is that few physicians are dealing specifically with the problems prevalent among adolescents. Substance use and abuse, sexually transmitted diseases, disorders of self-image, depression, suicide, and maltreatment of adolescents are highlighted in studies of adolescent health, yet they do not appear among the most common diagnoses, problems, procedures, or therapies associated with office-based visits. The 10-minute average length of visits by adolescents in physician offices hardly provides the time to elicit and deal with problems of such complexity (Irwin, 1986). In addition, many of the health issues of adolescents, such as drug use or sexual intercourse, are socially stigmatizing or difficult to discuss. Such issues make physician-patient relationships particularly difficult; adolescents may be

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Losing Generations: Adolescents in High-Risk Settings unwilling to present, discuss, or deal with these problems when physicians provide care (DuRant, 1991; Waitzkin, 1991). In addition, since many adolescents with these problems are seen in settings (categorical programs, neighborhood clinics, hospital-based adolescent clinics) that are not part of the national ambulatory care surveys, the incidence of these diagnoses is underreported in office-based practice data. As a result, adolescents—and especially adolescents who engage in high-risk behavior—have no apparent home in the U.S. medical system. They have relatively low visit rates in office-based practice, and their problems are poorly represented in standard medical data. The problem is exacerbated by a system of health services that is designed to provide specialty services rather than primary care. Most other industrialized countries have highly developed general practitioner services that serve as portals of entry into other services. The mode of payment and organization in the U.S. system permits and even encourages patients to seek care from specialists rather than generalists. No aspiring new specialty, including adolescent medicine, is required to specify whether its practitioners function as generalists for its target population or, rather, as a secondary (consultative) or tertiary (referral) resource for generalists (i.e., family physicians, general pediatricians, or general internists). As a result, it has been impossible to determine how many such specialists would be needed to serve the target population or to begin planning and organizing a health service system to meet adolescent needs. There is a growing consensus that the present health care system is too restricted and too fragmented, and that funds are not made available to respond effectively to the major health problems of adolescents. As a result, many have concluded that adolescent health services should be provided in alternative settings in the community. The defining features of these systems are an emphasis on prevention and outreach, consistent with a public health perspective on illness and health. The most frequently described option is school-based services. Currently only 1 percent of adolescents are served by clinics in schools. Although there have been some notable successes with school-based clinics, there is concern about the extent of their impact on health, the stability of their long-term funding, the commitment of school systems to maintain clinics when educational programs themselves are threatened by reductions in funding, and the fact that many clinics restrict the provision of family planning services by not offering contraceptives as an option for young people (Earls et

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Losing Generations: Adolescents in High-Risk Settings al., 1989; Millstein, 1988). Other alternatives include the provision of health and mental health services through "street-based" clinics and community-based youth development programs (see Chapter 10). Unfortunately, exposure of adolescents to these new services is often a matter of chance, social class, or area of residence, rather than need. Mental Health Services Approximately 25 percent of all adolescents are diagnosed with significant forms of emotional distress. Yet, as with the health system generally, it is misleading to speak of a mental health "system" for adolescents. Services are provided through special education in schools, community mental health centers, and inpatient facilities, but these components are poorly integrated and often unavailable to many youths who need them. Consequently, the mental health system meets the needs of a minority of adolescents, with some estimates indicating that up to three-quarters of adolescents with a diagnosable mental disorder do not have any contact with a mental health provider (Joint Commission on Mental Health of Children, 1969; President's Commission on Mental Health, 1978; Knitzer, 1982; U.S. Office of Technology Assessment, 1991b). Moreover, low-income and minority adolescents are the most likely to be denied access or to receive low-quality services (U.S. Office of Technology Assessment, 1991a; Cross et al., 1989; Berlin, 1983; Padilla et al., 1975). Mental health services have traditionally focused on treatment rather than prevention of illness or the promotion of emotional stability. The difficulties of this approach are well known. Affordability and access are both problems. Even for those young people for whom insurance is available, mental health treatment is offered only on a short-term basis, and often in restrictive inpatient settings. For example, anorexia nervosa, a growing problem among adolescent girls, is rarely covered by insurance programs, and the limit on payments for emotional illness is so low that institutions often cannot afford to deal with adolescents with these problems (see below). Within schools, less than one-third of all students in special education receive psychological, social work, or counseling services. There is only one school psychologist per 2,500 students nationwide, and only about 2 percent of all adolescents receive service from school psychologists (Meyers, 1989; Tremper, 1991). When preventive services are offered, they have been focused on the behavioral problems seen as being reflective

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Losing Generations: Adolescents in High-Risk Settings of poor mental health—substance abuse, violence, delinquency—rather than on the emotional well-being of young people themselves (U.S. Office of Technology Assessment, 1991b). HEALTH INSURANCE A comprehensive review of adolescent health insurance in 1979 and 1986 documented an estimated 25 percent increase in the proportion of adolescents (aged 10 to 18) without health insurance (U.S. Office of Technology Assessment, 1991b). By 1986, slightly more than 20 percent of all adolescents did not have public (Medicaid) or private health coverage, and young adults (aged 19 to 24) were even less likely to be covered (Newacheck and McManus, 1989). Near-poor adolescents are much less likely than their poor or nonpoor counterparts to be insured: fully one-third of near-poor youths completely lack coverage for their health care. By far the leading reason is that health insurance is too expensive (70 percent); an additional 11 percent report that they lost health insurance as a result of job loss in the family; only 6 percent lack insurance because they feel they do not need it or want it (Newacheck and McManus, 1989). The 1981 Omnibus Budget Reconciliation Act, through federal and state actions, limited eligibility for Aid to Families with Dependent Children, which in turn decreased eligibility for coverage by Medicaid. Lack of insurance coverage is not limited to those reared in poverty; about two-thirds of uninsured adolescents live in families with incomes above the poverty level. Private Coverage Even where it is available, insurance is inadequate for many adolescent problems. Treatment-oriented services dominate private health insurance plans (U.S. Office of Technology Assessment, 1991b). For example, virtually all employment-based private health insurance plans (which cover about 90 percent of individuals with private health insurance) cover diagnostic X-ray and laboratory tests, hospital room and board, inpatient and outpatient surgery, physician visits in the hospital and office, and inpatient mental health care. Such plans also generally provide coverage for outpatient mental health services (95 percent), prescription drugs (93 percent), substance abuse treatment (90 percent), home health care (86 percent), and extended care (79 percent). But preventive services are generally not covered by private

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Losing Generations: Adolescents in High-Risk Settings health insurance. For example, a minority of private health plans provide coverage for general dental care (37 percent), vision care (35 percent), immunizations (29 percent), routine physical exams (28 percent), hearing problems (27 percent), and orthodontia (27 percent) (U.S. Office of Technology Assessment, 1991b). These restrictions are especially important for adolescent well-being since they correspond directly to important acute and preventive needs of youth. Adolescents in low-income families that do not have private insurance, who are not eligible for Medicaid, and whose families are unable to pay out-of-pocket for preventive services are especially unlikely to receive such services. Thus, coverage by private health insurance does not guarantee access to all services that may be needed. Restrictions on payment (e.g., maximum amount, coinsurance, or deductibles) can be a deterrent to receiving services, especially for adolescents, for example (U.S. Office of Technology Assessment, 1991b): Limitations on the number of hospital days for treatment of mental illness and substance abuse place adolescents at a special disadvantage because their stays in the hospital are longer than those of adults. Preventive services for affective or behavioral disorders, such as depressed mood, conduct problems, or drug use, are often not covered. About one-third of privately insured adolescents are not covered for maternity-related services. At least eight states restrict private health insurance coverage of abortion services, and four others require it to be optional and at additional cost to the receiver. The extent of coverage for contraceptive services is unknown, as is coverage for diagnostic procedures related to pregnancy itself. Waiting periods and exclusion of preexisting conditions disproportionately affect employed adolescents because their duration of employment tends to be shorter than that for older employees. (Only 24 percent of employed adolescents receive health insurance through their employment.) Access to health care services may become even more restricted in the future. Health insurance coverage for dependents has been declining, requirements for cost-sharing have been increasing, and employers are eliminating many benefits such as coverage for substance abuse treatment (U.S. Office of Technology Assessment, 1991a). In addition, the rapid growth of self-insurance among the nation's employers appears likely to decrease the comprehensiveness

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Losing Generations: Adolescents in High-Risk Settings of services to those covered by the insurance, because self-insured plans are exempt from most state laws mandating that insurance plans include specified benefits. Medicaid Coverage For the 12 percent of insured adolescents who are covered by Medicaid, coverage is generally more complete than private insurance (Newacheck and McManus, 1989). There are no copayments or deductibles, and teenage mothers may establish eligibility on their own rather than through a parent. Federal regulations mandate minimum Medicaid benefits, but the 50 states vary widely in the extent to which they insure optional services. States can limit the frequency and number of covered services, decree certain services as not medically necessary, or restrict the sites where services are provided. Furthermore, like private health insurance, coverage of mental health services and substance abuse services is more extensive for inpatient than outpatient services, thus discouraging early or preventive care of these types of problems (U.S. Office of Technology Assessment, 1991b). The nature of the differences among states may be illustrated by comparing states at the extremes of their coverage. California provides Medicaid coverage for children of families with incomes up to 75 percent of the federal poverty level and up to 85 percent for pregnant women and infants. The state covers the full range of pregnancy-related services and also covers poor children in intact families up to age 21. In contrast, Alabama sets eligibility at 13 percent of the poverty level even for pregnant women, and it does not offer Medicaid to medically needy families or to poor children in intact families (Children's Defense Fund, 1991). Legislation in 1989 added Medicaid requirements that should have helped to address adolescent health needs. Coverage must now include a comprehensive history and physical examination, appropriate immunizations, laboratory tests, health education, and dental, vision, and hearing services. This legislation also permitted payment to medical practitioners to diagnose and treat any health condition discovered on screening, even though the services go beyond what the state would cover if the patient had presented the health problem. In practice, the states have concentrated almost three-quarters of these expenditures on pre-school-age children. Only 22 state programs covered five or more visits in adolescence, and patients aged 12-20 represent only 3.4 percent of all children served by the program (McManus et al., 1993).

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Losing Generations: Adolescents in High-Risk Settings The Medicaid expansion mandated by the Congress in 1990 will make all poor adolescents eligible for standard Medicaid by the year 2002. However, the limitations inherent in Medicaid will still restrict certain services. Access will continue to be through the family, so that teenagers will not be able to receive care on their own initiative. And even for adolescents who have their own Medicaid card, access to services is often only for certain conditions, such as family planning, sexually transmitted diseases, and pregnancy services. That is, the adolescent must have a defined health problem in order to receive services. Moreover, Medicaid does not reimburse costs for many of the services needed such as social work and nutrition, and the reimbursement for other services is so low that youths are essentially disenfranchised: for example, reimbursement for the treatment of substance abuse is so low as to be a disincentive to treatment (U.S. General Accounting Office, 1991). New developments in the Medicaid program hold promise of improving access to services for the poorest children over the next few years. The Medicaid eligibility reforms of 1990 required states to provide Medicaid coverage to children born after September 30, 1983, with family incomes up to 100 percent of the federal poverty level. Earlier legislation had made this provision optional, and there was wide variability among the states in the extent to which it was adopted. Thus, by the turn of the century, most of the poorest adolescents will be covered by Medicaid. State Medicaid coverage must now include periodic screening at intervals consistent with professionally set guidelines, must include health education and anticipatory guidance, and must cover treatment for all services identified at screening, as long as they are within federal guidelines. The improvement of services themselves may follow from other anticipated reforms, including those concerning the payment of physicians and those requiring states to monitor adolescent health. Consequences for Adolescent Health The service gaps that result from inadequate insurance are precisely for the types of health services most needed by adolescents who are at risk for unsuccessful transitions to adulthood. Specifically, coverage restrictions and reimbursement schedules ensure that relatively few adolescents receive preventive services, such as reproductive health or the necessary intervention for problems stemming from affective disorders or substance use. For example, gonorrhea and syphilis are sexually transmitted diseases whose

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Losing Generations: Adolescents in High-Risk Settings serious manifestations are preventable by good medical care, yet the prevalence of gonorrhea in 1988 was 65.1 per 100,000 adolescents aged 10-14, 1,072.9 per 100,000 age 15-19, and 1,241.5 per 100,000 aged 20-24. In the same year, the prevalence of syphilis (primary and secondary) was 1.0, 21.9, and 53.3 per 100,000, respectively, for the same age groups. The rates of syphilis increased by 25 percent, 46 percent, and 60 percent, respectively, between 1985 and 1990. Measles and mumps are completely preventable with immunization, yet adolescents constituted fully 48 percent and 62 percent of the reported cases of these two diseases in 1987 (Irwin et al., 1991). Predictably, uninsured adolescents are also less likely to receive medical care. They are less likely to have contacts with physicians (Newacheck and McManus, 1989); when they do have a regular source of care, it is less likely to be a physician and more likely to be a hospital clinic, a walk-in facility, or an emergency room (Blum, 1990). Although there is little research concerning the impact on adolescent health of access to care or a regular source of care, there is ample evidence for the population as a whole (see, for example, Starfield, 1992). Patients who have a regular source of care are more likely to be recognized as needing services, and existing mental and behavioral problems (such as those common in adolescents) are far more likely to be recognized if the regular source of care is a person rather than a place. People with a regular source of care have fewer emergency hospitalizations and shorter hospitalizations. They are less likely to contract preventable illnesses and more likely to comply with prescribed treatments and to keep follow-up appointments. When patients visit the same doctor over time rather than different doctors, care is more effective and less costly. Furthermore, interventions that involve sustained interactions between health professionals and families are more successful than those provided by a variety of separate sources. These interventions are even more effective when the service includes teams of professionals, especially home visitors, and when they include interactions with other services, in addition to the health care. SPECIAL PROBLEMS: CONFIDENTIALITY AND CONSENT Laws concerning parental consent and confidentiality of service pose additional barriers to adolescent health care (Bensinger

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Losing Generations: Adolescents in High-Risk Settings and Natenshon, 1991). Under public law, parental consent is generally required for the care of a minor child, on the assumption that such individuals lack the competence required to receive care and carry out the recommendations resulting from care. Other rationales for parental consent include the state's interest in involving the family in a child's care and the providers' interests in assuring that reimbursement will be received for the service care (U.S. Office of Technology Assessment, 1991b). The requirement for parental consent is generally waived under certain circumstances: when the adolescent can demonstrate his or her "independence" (e.g., marriage, maintenance of a separate domicile, or service in the armed forces) or for crisis situations (e.g., medical emergencies or when the adolescent is a victim of child abuse). Most states also allow minors to receive care for sexually transmitted diseases without the consent of a parent. Just under one-half of all states allow the provision of family planning services to minors without parental consent, although there are often considerable restrictions on what may be provided and to whom. About one-half of all states permit pregnant adolescents to receive care without parental consent. About one-fourth of all states require parental consent for abortions, a number that may soon increase. Just under one-fourth require parental notification of a minor's abortion decision, and about the same number provide for parental notification of pregnancy-related health services at the provider's discretion. Almost all states allow services to be provided without consent for substance abuse, but some include either drug-abuse or alcohol-related services but not both. A few states require parental notification of services related to substance abuse, and a few require it for mental health treatment. Slightly more than one-half of the states require parental consent for outpatient mental health services (U.S. Office of Technology Assessment, 1991b); somewhat fewer require such consent for inpatient mental health care, but generally adolescents can be committed without their consent to inpatient mental health care. Requirements for parental consent or notification interfere with the acceptability and receipt of needed health services in several ways. First, the widely discrepant and highly nuanced rules and regulations are confusing to recipients of services, who are unlikely to know to what they are entitled. Rather than facing possible rejection for services, they often find it easier to avoid seeking care. Second, the deterrent effect of parental notification in the case of family planning and abortion services may be extrapolated to other types of adolescent health services.

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Losing Generations: Adolescents in High-Risk Settings Problems of confidentiality and consent affect both conventional and community-based medical services for adolescents. Society as a whole has yet to reach consensus on the extent to which adolescents should be granted the freedom to make their own decisions about seeking and obtaining health services and the conditions under which such freedom might be granted. Since the adequate provision of medically appropriate services to adolescents may conflict with decision making in some families, a more consistent societal approach to resolving the inevitable conflicts would be needed to improve the situation regarding health care for adolescents. CONCLUSIONS The U.S. health system is woefully inadequate in dealing with the health of adolescents. Existing services do not address the most serious health risks facing adolescents, nor are they organized in a systematic or structured way, nor are they available or accessible to many of those with the greatest need for service. As a result, the adolescent health system not only fails to reduce the effects of other high-risk settings, but fails to protect adolescents from further risk to their health. Indeed, it is no exaggeration to say that ''there is no adolescent health care system in the United States." Yet adolescents face a higher risk of death from injury, homicide, and suicide than any other age group, and this risk appears to be rising. Other prevalent health problems include substance abuse, chronic illness and disability, sexually transmitted diseases, pregnancy and its outcomes, mental disorders (e.g., disorders of self-image, depression, suicide), and physical or sexual abuse. At the same time, however, adolescents are far less likely to visit a doctor's office or to have any regular source of medical care than are either younger children or adults. The current structure of the U.S. health system fails to address these needs. Few physicians specialize in adolescent health, and other practitioners are poorly trained in recognizing adolescent health problems, particularly when the symptoms are psychosocial rather than physical. The overall U.S. health care system is fragmented, especially for adolescents because of the diversity of their needs. Adolescents are unlikely to know where to go and are likely to be referred often before finding an appropriate setting. The adolescent health system lacks all of the essential elements of primary care: a consistent point of entry into the system, a locus of ongoing responsibility, adequate backup for consultation

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Losing Generations: Adolescents in High-Risk Settings and referral services by adolescent specialists, and comprehensiveness. Adolescents from low-income families—precisely those who are at highest risk for health problems—are also those least likely to be covered by health insurance. Moreover, even when available, insurance may be inadequate to the many needs of adolescents. Most private plans stress treatment rather than prevention or outreach, and payment restrictions (maximums, coinsurance, deductibles) further reduce the range of services available. Only 12 percent of low-income adolescents are currently covered by Medicaid, although for them the coverage is generally more complete than private insurance. However, the amounts and services covered by Medicaid can vary widely from state to state, and complicated regulations may discourage adolescents from seeking care. Rules regarding parental notification, which have a deterrent effect in the case of family planning and abortion, may also deter adolescents from seeking other health care services, and inadequate reimbursement schedules may cause providers to limit the number of Medicaid patients that they will serve. Current trends do not bode well for adolescent health services. With few exceptions, new health policies will compound the problems that adolescents are now experiencing. Families, communities, and the society at large are generally reluctant to accept adolescent values that diverge sharply from community norms; to the extent that adolescent health problems stem from generally unaccepted behavior, health services have not been adapted to respond to the needs of adolescents. And access to existing, though inadequate, health services may become more restricted as private insurance coverage decreases. Even the movement of the U.S. health system into managed care, with tight controls on the number and extent of services that may be provided, may further place adolescents in jeopardy because of the dearth of research on the effectiveness of treatment for adolescent health problems. This should be a major area of research interest in health care services research. REFERENCES Bachman, J., D. Johnston, and P. O'Malley 1991 Press Release: Summary of 1990 Senior Drug Use. University of Michigan News and Information Services, Ann Arbor. Bensinger, J., and A. Natenshon 1991 Difficulties in recognizing adolescent health issues. Pp. 381-410 in W. Hendee, ed., The Health of Adolescents. San Francisco: Jossey-Bass Publishers.

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Losing Generations: Adolescents in High-Risk Settings Berlin, I. 1983 Anglo adoptions of Native Americans: repercussions in adolescence. Journal of the American Academy of Child Psychiatry 17:387-388. Blum, R. 1987 Physicians' assessment of deficiencies and desire for training in adolescent care. Journal of Medical Education 62(5):401-407. 1988 Health insurance and medical care; health of our nation's children, United States. Advance Data from Vital and Health Statistics, No. 188. Hyattsville, Md.: National Center for Health Statistics. 1990 Adolescent medicine. Journal of the American Medical Association 263(19):2621-2623. Children's Defense Fund 1991 The State of America's Children. Washington, D.C.: Children's Defense Fund. Cross, T., B. Bazron, K. Dennis, et al. 1989 Towards a Culturally Competent System of Care: A Monograph on Effective Services for Minority Children Who are Severely Emotionally Disturbed. Washington, D.C.: Georgetown University. Dryfoos, J. 1990 Adolescents at Risk: Prevalence and Prevention. New York: Oxford University Press. DuRant, R. 1991 Overcoming barriers to health care access. Pp. 431-52 in W. Hendee, ed., The Health of Adolescents. San Francisco: Jossey-Bass Publishers. Earls, F., L. Robins, A. Stiffman, and J. Powell 1989 Comprehensive health care for high-risk adolescents: an evaluation study, American Journal of Public Health 79:999-1005. Eisenberg, L. 1984 The epidemiology of suicide in adolescents. Pediatric Annals 13(1):47-54. Fingerhut, I.A., and J.C. Kleinman 1989 Trends and current status in childhood mortality. U.S. 1900-85. Vital and Health Statistics, Series 3, No. 26, DHHS Pub. No. PHS 89-1410. Hyattsville, Md.: National Center for Health Statistics. Friedman, S.B., M. Fisher, and S.K. Schonberg 1992 Comprehensive Adolescent Health Care. St. Louis, Mo.: Quality Medical Publishers. Gallagher, J.R. 1960 Medical Care of the Adolescent. New York: Appleton-Century-Crofts, Inc. 1982 The origins, development, and goals of adolescent medicine. Journal of Adolescent Health Care 3:57-63. Gans, J.E., with D. Blyth, A. Elster, and L.L. Gaveras 1990 America's Adolescents: How Healthy Are They? Chicago: American Medical Association. Health Promotion 1987 Ottawa Charter for Health Promotion. Health Promotion 1(4):iii-v. Hendee W., ed. 1991 The Health of Adolescents. San Francisco: Jossey-Bass Publishers. Institute of Medicine 1989 Research on Children and Adolescents with Mental, Behavioral, and Developmental Disorders. Washington, D.C.: National Academy Press.

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