The Affordable Care Act (ACA) and Access to Care for Adolescents and Young Adults: Opportunities and Challenges to Improve Systems of Care Adolescent and Young Adult Health National Resource Center SAHM Annual Meeting Washington, DC March 9, 2016

Charles Irwin,Jr., MD 1 Elizabeth Ozer, PhD 1 Claire Brindis, DrPH 1,2 Charlene Wong, MD 3 Erin Hemlin 4 1 Division of Adolescent and Young Adult Medicine, UCSF Benioff Children’s Hospital, University of California, San Francisco 2 Philip R. Lee Institute for Health Policy Studies University of California, San Francisco 3 Division of Adolescent Medicine, University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, PA 4 Young Invincibles, Washington, DC

Acknowledgements Funder: Maternal and Child Health Bureau, Health Services and Resources Administration, USDHHS (cooperative agreement U45MC27709) Project Officer: Trina M. Anglin, MD, PhD

Introducing: The Adolescent and Young Adult Health National Resource Center Purpose: To improve adolescent and young adult health and address their health issues by strengthening the capacity of State Title V MCH Programs and their public health and clinical partners to better serve these populations (ages 10-25) Four-year cooperative agreement supported by MCHB ( )

University of California San Francisco University of Minnesota University of Vermont

The Adolescent and Young Adult Health National Resource Center Primary focus is improving receipt and quality of the well-visit among adolescents and young adults Under the new Title V/State Maternal and Child Health Program Block Grants: states had to choose at least one performance measure focused on adolescents. 38 states chose National Performance Measure #10: the percent of adolescents aged with a well- visit in the past year.

The Adolescent and Young Adult Health National Resource Center Major Activities: Collaborative Improvement and Innovation Network: State-based Quality improvement project focused on increasing well visit among AYAs Technical assistance to 38 states selecting NPM #10 Development of Tools and resources

Also visit the AYAH-NRC page:

Session Goals Participants can describe ACA provisions, impact and initiatives relevant to Adolescents and Young Adults Participants will identify strategies to help improve receipt of preventive services in their clinical settings, communities, states/country

Session Outline Background ACA Implementation and Impact

Most traditional markers of “adolescent” health worsen in young adulthood

Mortality by Cause, Sex and Age, Ages 10-24, 2014 Source: CDC Wonder, 2014 Ages Ages Rate per 100,000 Ages

Past-Month Substance Use, by Age, Ages 12-25, 2014 Source: National Survey of Drug Use and Health, SAMHSA 2015

Chlamydia—Rates by Sex and Age, United States, 2014

Challenges & Opportunities: Access Financial system well established. Financial system emerging. Organizational structure for care exists, with identified health care provider. No identified structure for care or provider, especially for males. Utilization mostly office based, with some clinics Utilization is more varied Minors under age 18; parents play major role. Family and legal context changes Major focus on preventive services, with some evidence Little focus on preventive care, despite evidence Adolescents Young Adults

Financial systems Fairly uniform public insurance coverage, especially post-ACA Public coverage varies more by state More likely to be covered by parents’ employer-based insurance Less likely to have employer- based coverage About 10% are uninsured About 25% are uninsured Adolescents Young Adults

Organization of Care Pediatric system of care exists, with pediatric provider as identified health provider. No identified organizational structure for care or provider for comprehensive primary health care Females have reproductive health access to some extent No identified provider for males. Adolescents Young Adults

Utilization of Care Usual Source of Care is mostly office based, with some clinics Fewer have a Usual Source of Care; Sources vary more: More utilization of clinics and other sources Adolescents Young Adults

Have a Usual Source of Health Care, by Sex and Age, Ages 10-25, 2014 Source: National Health Interview Survey, 2014.

Location of Usual Source of Care (of those with a USC), by Age, Ages 10-25, 2014 * Includes ER, hospital outpatient department, some other place, and don’t go to one Place most of the time Source: National Health Interview Survey, 2014.

Family and Legal Contexts Change Patchwork of confidentiality and consent laws, that differ in each state by Laws are the same nationally Health area (e.g., sexual health, substance use, mental health) Population (e.g., emancipated minors, pregnant adolescents) Adolescents Young Adults

Clinical Preventive Services Elizabeth M. Ozer, PhD AYAH-NRC Research Advisor

Evidence for effectiveness of clinical screening and counseling in some areas Greater evidence for effectiveness of clinical screening and counseling in some areas National consensus guidelines with champions since 1990s (GAPS; Bright Futures) with recognized schedule No major consensus guidelines or champions – no recognized schedule Guidelines consolidated into 3 rd edition of Bright Futures 2008 (4 th edition under development) Most guidelines are disease- specific, with recommendations varying by age (e.g., mammograms) Adolescents Young Adults Focus on Preventive Care

Past-Year Preventive Care Visit by Age and Gender, Ages 10-25, 2013 Source: Medical Expenditures Panel Survey, 2013.

The Adolescent Preventive Visit: 20 years of Consensus & Growing Evidence Base Guidelines in Bright Futures, 3 rd edition, endorsed by major health professional groups 4 th edition expected April 2016 – UNDER REVIEW Growing evidence for: -Health system interventions to increase clinicians’ delivery of services -Effectiveness of preventive service delivery on adolescent behavior change Source: Hagan, Shaw & Duncan, 2008

A comprehensive review of existing guidelines found evidence-based* recommendations in the following areas (Ozer et. al, 2012) : - Substance Use - Reproductive health - Mental health/depression - Nutrition/obesity - Safety/Violence - Infection disease/immunization Source: Ozer et al., 2012 Preventive Services for Young Adults * US Preventive Services Task Force and CDC, Advisory Committee on Immunization Practices

Additional Resources UCSF-NAHIC: Summary of Recommended Guidelines for Clinical Preventive Services for Young Adults ages 18-26, one-page clinical tool, with supplement  Evidence-based clinical preventive services fact sheet for AYAs  Visit our Clinical Services Resource Page at resource-page/ The ‘Preventive Services Evidence Fact Sheet’ is located at bottom of the page resource-page/

For more information and resources please visit

Overview of Affordable Care Act Provisions Claire D. Brindis, DrPH AYAH-NRC Co-Project Director

ACA Private Insurance Provisions Insurance Expansion - Marketplace/“State Exchanges” - Dependent coverage to age 26 Enrollment - In 2014, nearly half a million children (ages 0-17) enrolled in Marketplace coverage million young adults (ages 18-25) gained coverage due to dependent coverage provision Source: Alker and Chester, 2015; Uberoi, Finegold, & Gee, 2016.

ACA Public Insurance Provisions Medicaid for Adolescents (and younger children): -States required to expand Medicaid to 133% of the Federal Poverty Level. Medicaid for Young Adults : -State option to expand eligibility to 133% of the Federal Poverty Level for all adults. -32 States including D.C., chose expansion as of Feb 2016

Insurance Coverage by Age, Ages 10-25, 2010 & 2014 Source: National Health Interview Survey, Young Adults

ACA Preventive Service Provisions Access to Preventive Services - Provided by plans without cost-sharing to members - Requirements established by:  US preventive Services Task Force “A” and “B” recommendations  Bright Futures Guidelines for Children and Adolescents  CDC- ACIP Immunization Recommendations  HRSA-supported IOM recommendations for women’s health

Questions? Thoughts?

Lessons Learned From States Increasing Coverage & Preventive Visits for Adolescents and Young Adults (AYAs)

1.Calculated Insurance and Preventive Visit Rates - Data Sources: National Survey of Children’s Health & Behavioral Risk Factors Surveillance System  Pre- and post- ACA rates of insurance coverage  Pre- and post- ACA rates of preventive visits  Pre- and post- ACA change rates 2.Final Selection of States - Selection of top-performers ensured broad geographic and demographic representation - California, Colorado, Illinois, Iowa, Oregon, Texas, and Vermont 3.Interviewees - 25 MCH stakeholders (e.g., Title V Directors, Adolescent Health Coordinators, Youth Advocacy Organizations) Methods

Major Themes: Outreach & Enrollment Use of Community Agencies and Networks Focus on Special Populations Youth Engagement

Community Agencies TEXAS - Enroll Gulf Coast Began in 2013 to coordinate, network and streamline efforts to efficiently and effectively engage eligible population of Greater Harris County Comprised of 21 organizations (e.g., Change Happens, Children’s Defense Fund, and Young Invincibles) - Internal committees include: Intelligence, operations, and logistics Results: 190,000 Houstonians were enrolled in the first open enrollment period (Oct. 1, March 31, 2014) Source: Atkinson-Travis, 2014.

Major Themes: Outreach & Enrollment Use of Community Agencies and Networks Focus on Special Populations Youth Engagement

Six states focused on Hispanic/Latino, mixed- status, and undocumented youth - Oregon Health Authority designated state employees to directly oversee and coordinate outreach events (e.g., 3- day soccer tournament) - Texas’ Enroll Gulf Coast partnered with Univision to hold enrollment telethon Special Populations Racial/Ethnic

Children Now, a California non-profit, spearheaded CoveredTil26 campaign - Informational flyers - Social media campaigns - Direct outreach - County contact list of individuals who would help navigate enrollment in Medicaid (Medi-Cal) - Toolkit with sample language and resources for outreach to Former Foster Youth Special Populations Former Foster Youth

Major Themes: Outreach & Enrollment Use of Community Agencies and Networks Focus on Special Populations Youth Engagement

State-level Policy: - Youth Partnership for Health (CO): Public health department employs youth to provide feedback and recommendations on programs, practices, and policies State-level Media: - Oregon Health Authority: Youth advisory group created “one of the most successful” teen-friendly flyers Local-level Outreach: - Beacon Therapeutic (IL): Peer advocates that lived in homeless shelters and assisted in recruiting homeless AYAs

Source: Oregon Health Authority, 2011.

Major Themes: Preventive Care Visits Commitment to Bright Futures Guidelines Focus on Medical Homes Capacity-Building

Commitment to Bright Futures Guidelines Vermont, 2008:  State’s Medicaid program adopted Bright Futures as standard of care  AAP Chapter organized ‘roadshows’ to educate providers about Bright Futures Illinois, 2011:  State’s Medicaid program adopted Bright Futures as standard of care Colorado, 2014:  State’s EPSDT program adopted Bright Futures’ Periodicity Schedule. Source: States & Communities, 2015; EPSDT, 2015.

Major Themes: Preventive Care Visits Commitment to Bright Futures Guidelines Focus on Medical Homes Capacity-Building

Focus on Medical Homes Colorado Medical Home Initiative, Goal to ensure all children receive care within a medical home - Brings together over 40 representatives from government agencies, health providers, NGOs, and policy-makers Legislation in 2007 established medical homes for children in Medicaid Results: By 2012, 45% of children in Medicaid/CHIP had a medical home compared to 41% in 2007 Source: Fast Facts, 2015; National Survey of Children’s Health, 2015.

Major Themes: Preventive Care Visits Commitment to Bright Futures Guidelines Focus on Medical Homes Capacity-Building

Capacity-Building Vermont Youth Health Improvement Initiative - Started in 2001 to support pediatric and family practices to improve preventive services delivery for youth ages Results: 69 practices have been assisted in improving the quality of health care they provide Child Health Advances Measured in Practice - Started in 2012 to increase the efficiency, economy, and quality of care provided to Medicaid-eligible children and families - Results: 40 practices (95% pediatric) have participated in annual QI projects Source: YHII, 2015

Achieving NPM #10/ Increasing Preventive Visit Rates for Adolescents: Where Can States Make a Difference? Providers Local Government Agency Networks StateFederal