Overview of Health Care Systems & Utilization Among Young Adults Charles E. Irwin, Jr., MD Distinguished Professor of Pediatrics Project Director, Adolescent & Young Adult Health National Resource Center Director, Division of Adolescent & Young Adult Medicine Department of Pediatrics UCSF Benioff Children’s Hospital, San Francisco University of California, San Francisco National Millennial Health Summit Washington, D.C. September 28, 2016

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) http://nahic.ucsf.edu/resources/resource_center/

The Adolescent and Young Adult Health National Resource Center Four-year cooperative agreement (2014–2018) Project Officer: Trina M. Anglin, MD, PhD Funder: Maternal and Child Health Bureau, Health Services and Resources Administration, USDHHS (cooperative agreement U45MC27709)

University of California San Francisco University of Minnesota University of Vermont

Session Overview Critical Health Issues of Young Adulthood Healthcare Challenges & Opportunities Healthcare Utilization: Pre- Post ACA Looking Ahead

Critical Health Issues of Young Adulthood Motor vehicle crashes & drinking and driving. Violence, including homicide, fighting & intimate partner violence. Reproductive & sexual health, including STIs, HIV/AIDS & unintended pregnancy.

Critical Health Issues of Young Adulthood Critical period for emergence of: Mental health problems (e.g., depression, suicide and suicide attempts). Substance use (e.g. Tobacco/ENDS, binge drinking, and use of marijuana & other illicit drugs).

Mortality by Cause, Sex and Age, Ages 10-24, 2014 Rate per 100,000 16.8 Ages 10-14 Ages 15-19 Ages 20-24 Source: CDC Wonder, 2014

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

Past-Year Major Depressive Episode, by Age and Sex, 2014 Source: Center for Behavioral Health Statistics and Quality, 2015

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

Session Overview Critical Health Issues of Young Adulthood Healthcare Challenges & Opportunities Healthcare Utilization: Pre- Post ACA Looking Ahead

Healthcare Challenges for Young Adults Access Financial system emerging No identified structure for care or provider, especially for males Source of care is varied Explanation of Benefits (EOBs) create confidentiality issues – dependent on the policyholder Little focus on preventive care, despite evidence Financial Systems Public coverage varies more by state Less likely to have employer-based coverage About 18% of young adults (aged 18-25) are uninsured* *Behavioral Risk Factor Surveillance Survey, 2015

Healthcare Challenges for Young Adults Organization of Care 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. Utilization of Care Few have a Usual Source of Care Sources vary more: More utilization of clinics, Urgent Care/ERs, and other sources

Have a Usual Source of Health Care, by Sex and Age, Ages 10-25, 2014 NHIS, Have a Usual Source of Care: Definition: Usual place When Sick: place one usually goes to when he/she is sick or when parent needs advice about his/her health (no time frame) Measure: Is there a place that you USUALLY go to when you are sick or need advice about your health? 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.

Healthcare Opportunities for Young Adults Increased focus on young adulthood (IOM) Insurance Expansion Medicaid Expansion 32 States including D.C. have expanded as of July 2016 Marketplace/“State Exchanges” Dependent coverage to age 26

Healthcare Opportunities for Young Adults ACA Preventive Care Provisions Provided by plans without cost-sharing Required services drawn from: US Preventive Services Task Force “A” and “B” recommendations Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents ACIP Immunization Recommendations HRSA-supported IOM recommendations for women’s health

Preventive Services for Young Adults A comprehensive review of existing guidelines found evidence-based* recommendations in the following areas: Substance Use Reproductive Health Mental Health/Depression Nutrition/Obesity Safety/Violence Infectious Disease/Immunization *US Preventive Services Task Force and CDC, Advisory Committee on Immunization Practices Source: Ozer et al., 2012

Preventive Services for Young Adults Why focus on the well-visit? It works! Opportunity to provide evidence-based preventive services. Young adults are more likely to receive preventive services if they have attended a well visit. Source: Ozer et al., 2012

Session Overview Critical Health Issues of Young Adulthood Healthcare Challenges & Opportunities Healthcare Utilization: Pre- Post ACA Looking Ahead

Receipt of a WELL VISIT among young adults, Ages 18-25, by Year and Measure, MEPS * Rates significantly higher in 2011-13 Source: Medical Expenditures Panel Survey

Receipt of ANY health care visit among young adults, Ages 18-25, Constructed Method by Year, MEPS Source: Medical Expenditures Panel Survey

Preventive services received by receipt of past-year well visit among young adults, Ages 18-25, MEPS 2007-2013 * Rates significantly higher among those with a past-year well visit Source: Medical Expenditures Panel Survey

Preventive services received among young adults with a past-year well visit, Ages 18-25, by Year, MEPS * Rates significantly higher in 2011-13 Source: Medical Expenditures Panel Survey

Session Overview Critical Health Issues of Young Adulthood Healthcare Challenges & Opportunities Healthcare Utilization: Pre- Post ACA Looking Ahead

Looking Ahead: Improving Access to Preventive Services Young Adults: Focus on health literacy: Inform consumers about the preventive services recommended for young adults Inform consumers the preventive visit is free under every health plan Develop tailored messages on the importance & value of preventive visits Clinicians: Educate providers about evidence for young adult services Train providers on evidence for clinical preventive services

Looking Ahead: Improving Access to Preventive Services Health System: Encourage health care systems to expand opportunities for preventive services (e.g., scheduling, reminders) instead of acute care Legal System: Inform health care systems about state laws regarding EOBs Educate consumer about how EOBs work