The Affordable Care Act and implications for young adult health

ABSTRACT

In the USA, young adults are most likely to be uninsured and least likely to report a usual source of medical care than any age group. The Patient Protection and Affordable Care Act (ACA) recognizes the critical need for expanded insurance coverage for this age group, and multiple provisions of the ACA address insurance coverage and health care utilization in young adults. This paper presents a brief overview of the challenges of maintaining health insurance coverage and accessing health care in young adults, provisions of the ACA relevant to young adults, and early impact of the ACA on young adult health insurance status and health care access and utilization. We offer policy suggestions for behavioral health providers to address continued challenges related to health care for young adults.

INTRODUCTION

In the USA, young adults historically have been at the greatest risk for having insufficient or no health insurance coverage [1]. This critical issue has been addressed in recent legislative efforts to improve access to and quality of health care for all Americans. Many key provisions of the Patient Protection and Affordable Care Act (ACA) expand health insurance coverage options for young adults (ages 18–25) [2]. The ACA is a strong initial attempt to provide increased insurance coverage for young adults; however, the current provisions of the ACA are inadequate to address some of the systemic issues related to health care access and utilization among young adults. The goals of this commentary are to review current provisions of the ACA relevant to young adults, present data to date on the impact of the ACA, and offer policy recommendations that have the potential to further improve health in young adults. We will identify ways that behavioral health care providers can work to close gaps of the ACA related to young adults.

YOUNG ADULT HEALTH PRIOR TO THE ACA

In 2011, the Centers for Disease Control reported that 25.9 % of all 18–24 year olds were uninsured. Young adult males were the least likely to have health insurance coverage, with 28.3 % of males ages 18–24 reporting no insurance coverage [1]. Household income is closely linked to insurance status. Young adults from lower income households are less likely to report having insurance coverage [1], and in 2011, the average annual income of uninsured young adults was $12,000 [3].

Prior to the ACA, one of the primary reasons for uninsurance during young adulthood was the loss of insurance coverage through public or private sources when a young adult turned age 18 or 19. Traditionally, a youth on public insurance aged out of Medicaid or a Children's Health Insurance Program (CHIP) at age 19. Similarly, young adults were excluded from a parent's insurance policy at high school or college graduation [2]. Young adults with special health care needs, the most vulnerable group of young adults who rely on consistent access to medical care, are not immune from the lack of insurance coverage available to young adults. Results from the 2007 National Survey of Adult Transition and Health found a 20 percentage point increase in the proportion of uninsured youth from adolescence (ages 14–17) to young adulthood (ages 20–23) [4]. Kirchoff and colleagues analyzed data from the 2009 Behavioral Risk Factor Surveillance System and found that 21 % of young adults with a cancer history reported no health insurance coverage [5].

Lack of health insurance coverage plays a significant role in access to and utilization of health care services. Data from the 2009 Medical Expenditure Panel Survey found that young adults ages 18–26 had the lowest health utilization rate of any age group [6]. In 2011, only 77.9 % of women and 62.5 % of men aged 19–25 years reported a usual place for health care [1]. More alarmingly, 28 % of uninsured young adults ages 19–25 reported delaying or forgoing needed medical care due to cost, as compared to 10.1 % of young adults with public insurance and 7.6 % of young adults with private insurance coverage [1]. Poorer health status has been associated with increased barriers to accessing health care. Kirchhoff and colleagues found that 44 % of young adult cancer survivors reported forgoing medical care due to cost [5]. Additionally, young adults are high users of acute care. In 2011, 35.9 % of publically insured young adults, 25.1 % of uninsured young adults, and 18.3 % of privately insured young adults reported at least one visit to the emergency department in the past year [1].

Lack of access to health services and poor utilization contribute to low rates of receipt of preventive health services in young adults. Data from the 2005 and 2007 California Health Interview Surveys found universally low rates of preventive services in a diverse sample of young adults ages 18–26. Although 70 % of the sample reported a usual source of health care, only 16.7 % reported receiving a flu vaccine, 18.1 % reported diet counseling, 21.5 % reported receiving emotional health screening, and 42.2 % reported screening for a sexually transmitted disease in the past 12 months. Receipt of preventive services was significantly higher for females, insured young adults, and young adults with a usual source of care [7]. However, the lack of consistent preventive screening suggests that access and utilization of health services in young adults could be improved.

Thus, the pre-ACA health system has significant flaws in the provision of coverage for young adults, leading to high numbers of uninsured young adults, decreased access to health care, and inconsistent health care utilization. Next, we will discuss how the ACA has responded to this significant public health need and the provisions of the ACA relevant to young adults.

PROVISIONS OF THE ACA APPLICABLE TO YOUNG ADULTS

One of the first provisions of the ACA to be implemented aimed to decrease the number of uninsured young adults. Starting in 2010, the ACA extended the age that young adults can remain on a parent's insurance plan and mandated that all insurance plans maintain dependent insurance coverage—at the same price—to enrollee's adult children up to age 26 [8]. The ACA superseded state laws by eliminating exceptions related to living situation, marital status, or student status [9].

An additional provision to be enacted in 2014 expands Medicaid coverage for all adults with incomes ≤133 % of the federal poverty level. Traditionally, public insurance has only been available to the most vulnerable populations, including children, pregnant women, those with special health care needs (e.g., disability), low-income adults with dependent children, and older adults. Expansion of eligibility for all adults with annual incomes below 133 % of the federal poverty level should open up public insurance options for young adults, including young adults with special health care needs and young adults who are unable to join or remain on a parent's insurance plan. Further, young adults with annual incomes ≤400 % of the federal poverty level will be eligible to access new private health insurance plans through state health insurance exchanges. Income-based subsidies will be available to offset costs of health insurance in relation to household income. As the average income of uninsured young adults is $12,000 [3], these two components of the ACA should provide vastly increased options for public or private insurance coverage beginning in 2014. Also starting in 2014, the ACA prohibits health insurance companies from denying coverage for preexisting conditions, further increasing health insurance access for youth with special health care needs [10].

Changes in coverage for preventive services may also improve health in young adults. As of 2010, insured young adults can obtain preventive services with no copay or additional costs. Specific preventive services covered include tests for sexually transmitted infections; counseling related to nicotine or alcohol use, weight loss, nutrition, and emotional health; vaccinations and flu shots; and prenatal care [11]. Beginning in 2014, the ACA also requires all new insurance plans to cover mental health as one of the essential health benefit categories [12]. Given the lack of preventive and mental health services traditionally utilized by young adults [7,13] and delay of health services due to costs [1,5], greater availability of preventive and mental health services at no or low cost may significantly increase the proportion of young adults receiving screenings, preventive care services, and mental health treatment.

EARLY IMPACT OF THE ACA ON HEALTH CARE ACCESS AND UTILIZATION

Early estimates indicate that the ACA has led to new insurance coverage for approximately three million young adults from September 2010 to September 2011 [14]. Insurance coverage rates increased across all demographic groups [14], including men, racial minorities, unmarried young adults, and young adults in fair to poor health [14,15]. The majority of newly insured young adults reported private insurance coverage. There were no change observed in percentage of young adults reporting Medicaid coverage and a slight decline in young adults with insurance policies in their own names [15].

Data from the Commonwealth Fund demonstrated similar trends, finding that 13.7 million young adults reported that they remained on or rejoined a parent's insurance plan between November 2010 and November 2011. The Commonwealth Fund estimated that approximately 6.6 million of these young adults would not have been eligible for coverage prior to the ACA, increasing the likelihood that this group would have been uninsured or underinsured before the ACA [8]. Young adults with higher incomes were more likely to be covered under a parent's insurance policy, with 69 % of young adults with family incomes ≥400 % of the federal poverty level joining or remaining on a parent's insurance plan as compared to only 17 % of youth with family incomes ≤133 % of the federal poverty level [8].

Research on health care utilization is emerging. Sommers and colleagues compared health access indicators between young adults ages 19–25 and adults ages 26–34 (not included in ACA expanded coverage until 2014) and found a significant decrease in the number of young adults reporting delaying or forgoing medical care due to cost from September 2010 to September 2011. This decrease was greater in young adults than in the control group of adults ages 26-34 [14]. Additionally, there was a significant increase in young adults reporting a usual source of health care during the same time period; however, this difference was not significant when compared to the control group. The overall impact was greater for coverage rates than health care access, with a 2.3 percentage point decline in forgone care and a 4.0 percentage point decline in delayed care for each 6.7 percentage point increase in coverage [14]. Changes were more evident over time, paralleling the duration of time since enactment of ACA provisions [14].

POLICY RECOMMENDATIONS TO IMPROVE YOUNG ADULT HEALTH

The ACA policies are an excellent first step in improving the health of young adults in the USA. Increasing enrollment options for public and private insurance, particularly Medicaid programs for low-income independent young adults, directly addresses the public health problem of high rates of uninsured young adults. The ACA also increases the safety net for young adults to remain as covered dependents on a parent's insurance plan [14]. We expect to see an additional sharp increase in the number of insured young adults after the 2014 regulations expanding Medicaid eligibility and creating state-run health insurance exchanges are implemented.

Improving access to care for young adults

By increasing insurance coverage options, supporters of the ACA are optimistic that access to health care will also increase. Early ACA data supports increased health care access and utilization, as fewer young adults report delaying or forgoing medical care due to cost [14]. However, there has not necessarily been a differential impact on the number of young adults who report a usual source of care. Systematic changes in the delivery of health care services could encourage more young adults to access a usual source of health care. For example, the schedules of health care practices often are not conducive to the schedules of young adults. Young adults are often unable to contact a physician over the telephone or via e-mail or obtain care after hours. Given the high rates of emergency department use in this population, increasing access to care providers after hours could reduce emergency department visits and promote more consistent access to health services [16,17]. These services should be differentially incentivized and reimbursed through health insurance [18].

Adding incentives for health care providers trained in young adult issues

Medical residency training programs are also developing specialized training in adolescent/young adult medical care. Increasing the number of providers trained to work with youth during this critical developmental period may increase engagement with medical care and promote better health outcomes. Thus, system-level changes to promote training in young adult medicine such as incentives for providers seeking specialized training in this developmental period (e.g., loan repayment programs) will grow a specialized workforce ready to work with this vulnerable population [19]. Behavioral health providers may also benefit from specialized training in developmental issues relevant to young adults.

Increasing use of preventive services

It is unknown if the ACA legislation has had any impact on receipt of preventive services to date. However, prior to ACA implementation, up to 70 % of young adult visits to primary care physicians included no preventive counseling [20]. Additionally, a recent review of preventive guidelines found that no specific guidelines exist for young adults, even though their developmental needs are markedly different from those of adolescents or older adults [21]. Primary care services should be reimbursed for preventive visits and should have care goals for young adults that include routine preventive screenings [21].

Improving integration of mental and behavioral health services for young adults

Finally, the impact of ACA legislation on mental health has yet to be evaluated. Mental health and related behavioral health services are a critical component in health promotion in young adults. Behavioral medicine specialists play a key role in enhancing and maintaining behavior change for many key issues facing young adults, including obesity, drug and alcohol use, depression, and sexually transmitted infection [22]. The ACA includes emotional screening as part of the mandated preventive services delivered at no charge to the patient and provides a federal mandate for mental health parity [11,12]. Traditionally, access to mental health services has been challenging due to limited benefits for mental health and reimbursement policies that discourage routine primary care screening for emotional and behavioral issues [23]. The ACA legislation has the potential to reduce barriers to accessing mental health services. For example, primary care screening for depression in adolescents and adults is feasible and leads to treatment that improves depression outcomes [24,25]. Behavioral health providers should work with primary and specialty care systems to increase use of emotional screening tools and ensure adequate follow-up with at-risk patients. Thus, the ACA may also enhance collaborative relationships among primary and specialty care providers and behavioral health specialists. Increased attention should be paid to how to incorporate behavioral medicine professionals into primary and specialty care.

CONCLUSION

The ACA includes numerous provisions that have the potential to improve the physical and emotional health of young adults. The primary mechanism of change to improve health is through expanding insurance eligibility and coverage for this vulnerable group. In addition, increased attention to preventive care and mental health may positively impact young adult health. Research should evaluate uptake of these services in the early years of ACA implementation to determine how to maximize access for and usage by young adults. In tandem with the ACA legislation, additional policies are needed to improve young adult access to and engagement in medical care, augment and incentivize training opportunities for practitioners specializing in young adult health, and increase consistent access to behavioral and mental health care in primary and specialty care settings. Behavioral medicine specialists must play a critical role in advocating for targeted health policy advances aimed to improve young adult health.