The Unique Health Care Needs of Adolescents

Health insurance coverage plays a key role in
meeting adolescents? needs by increasing
their access to health care, yet adolescents
are more likely to lack coverage than
younger children.1 One in seven adolescents ages 10 to
18 has no form of public or private insurance.2 Even
higher rates of uninsurance are found among lowincome,
black, and Hispanic adolescents. For lowincome
adolescents, insurance through public programs
such as Medicaid and the State Children?s Health Insurance
Program (SCHIP) is particularly important. Like
younger children without coverage, adolescents without
insurance use fewer health services, receive care less frequently,
return for fewer follow-up appointments, and
are more likely to seek care in an emergency room.3,4
While most adolescents are healthy by traditional medical
standards, a significant number of young people
experience some serious physical or mental health problems
or concerns. For example, approximately one in
five adolescents suffers from at least one serious health
problem, such as chronic conditions, asthma, or depression;
and about one in four is believed to be at risk for
early unprotected sexual intercourse or substance abuse.5
Moreover, many health problems occur disproportionately
among adolescents who are Medicaid and SCHIP
eligible. Low-income adolescents, especially those of
color, have higher rates of death, illness, and health risk
behaviors in almost every category studied.6 In addition,
other subgroups of adolescents face special, heightened
health risks and are more likely to have acute and complex
health care needs. These groups include youth who
have chronic physical or mental health conditions; live in
foster or group homes; are homeless or have run away
from home; are undocumented, migrant, or new immigrants;
have limited English language skills; are incarcerated
or involved in the juvenile justice system; or are
pregnant or parenting.7
Making adolescent health a priority is especially timely
because significant demographic changes are occurring
in the United States. While adolescents will represent a
smaller proportion of the overall population, the number
of adolescents ages 10 through 19 is expected to
grow from 39.8 million in 2000 to 42.3 million in 2020,
a 6.4% increase.8 Moreover, adolescent population projections
anticipate far greater numbers of young people
of color, who are more likely to live in poverty, be uninsured,
and underutilize primary and preventive health
care services.9
This article describes the particular health care needs of
adolescents and explores the extent to which public
Claire D. Brindis, Dr.P.H., is a professor of pediatrics
and health policy with the Division of Adolescent Medicine
and the Institute for Health Policy Studies at the
University of California, San Francisco.
Madlyn C. Morreale, M.P.H., is deputy director of the
Center for Adolescent Health & the Law.
Abigail English, J.D., is director of the Center for
Adolescent Health & the Law.
Volume 13, Number 1
health insurance programs are meeting those needs. It
includes an overview of the coverage available to adolescents
through Medicaid and SCHIP, how that coverage
has evolved, the importance of providing comprehensive
benefits to adolescents, and the need to adopt ageappropriate
quality and performance measures to track
progress over time. Throughout the article, recommendations
are provided to strengthen health care services
for adolescents, informed by the work of several national
health care and policy organizations.10
Special Health Care Needs of Adolescents
Adolescence is a unique developmental stage of accelerated
growth, when a number of physiological, cognitive,
social, and emotional changes occur simultaneously.
Despite the lack of a formally established age range to
define this developmental period, health professionals
generally consider adolescence to include young people
ages 10 through 19, or those ages 10 through 24.11 During
the transition from childhood into adolescence and
again from adolescence into adulthood, youth have complex
and important health care needs. Also, adolescence
is a critical time to avoid the onset of health-damaging,
risky behaviors such as smoking and unsafe sexual activity
that can lead to lifelong health problems. Thus, health
care services for adolescents need to emphasize prevention,
early intervention, and education.
Risk-Taking Behavior
Seven categories of risk-taking behavior account for 70%
of adolescent illness, injury, and death: drug and alcohol
abuse; unsafe sexual activity; violence; injury-related
behavior; tobacco use; inadequate physical activity; and
poor dietary habits.12 Many of these same health-damaging
behaviors are related to the majority of adult death
and illness.13 Furthermore, adolescents? perception and
assessment of risk seem to differ from adults?. For example,
studies suggest that while teens understand the risks
involved with engaging in certain behaviors such as
smoking, they believe that negative consequences associated
with those risks are more likely to affect other people
than themselves.14
Overall, there is a lack of consensus about the factors
underlying adolescents? risk-taking behaviors. Nevertheless,
to reduce the prevalence of such behaviors, a range
of responses?including preventive health services, legislative
and regulatory initiatives (such as those meant to
reduce access to cigarettes), and other strategies?likely
will be needed.15
Preventive and Primary Care
Prevention and primary care services are particularly
critical for adolescents because many of the most serious,
costly, and widespread adolescent health problems?
including unintended pregnancy, sexually
transmitted infections, and substance use?are potentially
preventable.16 Early intervention and preventive
care could improve adolescents? physical and mental
health and reduce death and illness.17 Through education,
screening, anticipatory guidance, counseling, early
intervention, and treatment, preventive care can help
establish healthy habits that last a lifetime.18 However,
insurance coverage of these services has been uneven
and limited. Many adolescents, both those covered in
Medicaid and SCHIP as well as those with private
insurance coverage, do not receive necessary and appropriate
preventive care.19
Medicaid and SCHIP both offer a basis for providing
low-income adolescents with some essential preventive
services, such as regular comprehensive health assessments.
For low-income adolescents who are entitled to
receive Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT) services through Medicaid, many
prevention components are included as required elements
of a screening visit, and many SCHIP programs
also include well-adolescent visits as a benefit. To increase
the likelihood that adolescents will actually receive these
benefits, purchasers could track them using the Health
Plan Employer Data and Information Set (HEDIS)20 or
other quality-measurement tools.
Improving Access to Publicly Subsidized
Health Insurance for Adolescents
Medicaid and SCHIP represent the two most significant
sources of publicly funded health insurance for lowincome
children and adolescents. Several researchers and
organizations have examined the unique challenges of
and opportunities for serving adolescents in Medicaid
and SCHIP.21?24 These studies have found that Medicaid
and SCHIP offer the potential to provide comprehensive
health insurance coverage to millions of adolescents, and
that states have made progress toward covering adoles-
118
Brindis, Morreale, and English
Health Care Needs of Adolescents
cents in recent years. Nevertheless, the extent to which
states implement these programs so that eligible adolescents
fully benefit has yet to be determined, and several
challenges to serving this population remain.
Adolescents? Eligibility
Historically, adolescents were less likely than younger
children to be eligible for public coverage under Medicaid,
but program expansions adopted in the late
1980s and early 1990s and the creation of SCHIP in
1997 significantly increased adolescents? eligibility for
public coverage.25
Medicaid is jointly financed and administered by states
and the federal government. States may vary program
guidelines as long as they adhere to federal standards or
receive federal permission (in the form of a waiver) to
depart from those standards.26 Thus, adolescents? eligibility
for Medicaid?along with benefits, provider reimbursement,
and many other issues of critical importance
to youth and their families?varies by state.
Federal Medicaid law specifies a number of groups that
must be covered in every state (referred to as ?mandatory
eligibility categories?) and groups that may be covered
if the state chooses to do so (referred to as ?optional eligibility
categories?).27,28 Before 1988, Medicaid eligibility
for children and adolescents essentially was limited to
those who qualified on a ?categorical? basis, such as
those whose parents received cash assistance, Supplemental
Security Income for disabilities, or federal foster care
or adoption assistance.
Between 1988 and 1990, Congress enacted several laws
that required states to expand coverage to children and
adolescents based on family income.29,30 Among these,
the Omnibus Budget Reconciliation Act of 1990 was
most important for adolescents. It required states to
gradually phase in Medicaid coverage (one year at a time)
for poor children and adolescents ages 6 through 18, so
that by October 1, 2002, all poor adolescents under age
19 would be eligible.31
Beyond the mandatory phase-in of coverage for poor
adolescents, two optional Medicaid expansions of the
1990s were of particular importance: an option that
allows states to provide Medicaid eligibility to age 21
for young people who ?age out? of the foster care system
after their eighteenth birthdays;32 and an option
that allows states to disregard certain income and assets
and to provide coverage for children and adolescents
beyond the age or income levels set as minimums under
federal law.33
119 The Future of Children
Despite these expansions, progress across the states has
varied, and Medicaid still serves significantly more
infants and younger children than adolescents. During
Fiscal Year 1999, the latest year for which data are available,
Medicaid served more than twice as many children
under age 6 and children and adolescents ages 6
through 14 as it served older adolescents ages 15
through 20.34 (See Figure 1.)
The creation of SCHIP in 1997 expanded the potential
for states to provide public health insurance coverage to
adolescents in two significant ways. First, the population
eligible for SCHIP (called ?targeted low-income children?)
includes children and adolescents under age 19 in
families with incomes less than or equal to 200% of the
federal poverty level (FPL) in most states.35 In addition,
the definition of ?targeted low-income children?
excludes children and adolescents who are eligible for
Medicaid, based on eligibility standards in effect on
March 31, 1997, and those who do not have access to
other insurance.36 This definition particularly benefited
adolescents because they were both less likely than
younger children to have been eligible for Medicaid
before SCHIP and less likely to have private insurance
coverage. By September 30, 2001, only five states did not
provide Medicaid coverage to all poor adolescents under
age 19: Colorado, Montana, Nevada, Pennsylvania, and
Utah did not accelerate the mandatory Medicaid phasein
schedule to cover poor adolescents to a higher age
than federal law requires.
Second, because the federal match for SCHIP is more
generous than the match for Medicaid, Congress essentially
provided states with a financial incentive to use
SCHIP funds to accelerate the phase-in of Medicaid eligibility
for poor adolescents.37 As a result, while only 14
states provided Medicaid coverage to all poor adolescents
under age 19 as of March 31, 1997, by September 30,
2001, 46 states (including the District of Columbia) provided
Medicaid or SCHIP coverage to all poor adolescents
under age 19.38
When looking at the highest income level at which adolescents
are eligible for public insurance (either SCHIP or
Medicaid), states? progress is similarly impressive (see Figure
2). On March 31, 1997, only 6 states provided Medicaid
coverage to all adolescents under age 19 in families
with incomes above 100% of the FPL.39 By September
30, 2001, all but 12 states provided SCHIP or Medicaid
eligibility to all children and adolescents under age 19
with family incomes up to at least 200% of the FPL.40
Progress in Expanding Coverage
During Fiscal Year 2001, nearly 4.5 million children and
adolescents under age 19 were enrolled in SCHIP, and
nearly one-third (32%) of these enrollees were between
ages 13 and 18.41 An interesting picture emerges when
SCHIP enrollment data are analyzed by both age group
and program type. First, older adolescents were more
likely than younger children to have been enrolled in
Medicaid expansion SCHIP?36% of adolescents ages 13
to 18 were enrolled in Medicaid expansion SCHIP, compared
with 22% of children and adolescents ages 6
through 12 and 16% of children under age 6.42 Second,
Volume 13, Number 1 120
Brindis, Morreale, and English
Figure 1
Children and Adolescents Served by Medicaid,
Fiscal Year 1999
Source: Based on data from Centers for Medicare and Medicaid Services. Table 2.
Medicaid eligibles?Fiscal Year 1999, by age group, all states. Available online at
http://www.cms.gov/medicaid/msis/99total.pdf.
9.5
8.9
4.3
Under Age 6 Ages 6?14 Ages 15?20
10
9
8
7
6
5
4
3
2
1
0
Number Served (in millions)
Health Care Needs of Adolescents
although more children and adolescents of all ages were
enrolled in state-designed SCHIP programs than in
Medicaid expansion SCHIP, adolescents ages 13 through
18 represented nearly one-half (46%) of all Medicaid
expansion SCHIP enrollees, but only 28% of enrollees in
state-designed SCHIP programs during Fiscal Year
2001.43 (See Figure 3.)
The distinction of enrollment by program type is important
because it has implications for the benefits that
enrollees may receive, and for whether or not eligibility
is an entitlement. For example, because Medicaid is an
entitlement program, children and adolescents covered
by Medicaid expansion SCHIP will remain eligible for
Medicaid even if a state has used up its allotment of
SCHIP funds.44,45 By contrast, there is no entitlement to
eligibility in a separate (non-Medicaid) SCHIP program,
which means that states can limit services to eligible children
and youth by placing them on waiting lists or by
capping enrollment.
The proportion of SCHIP enrollees who are adolescents
varies considerably by state. During Fiscal Year 2001, for
example, adolescents ages 13 through 18 represented
anywhere from less than 25% of total SCHIP enrollment
(in four states) to 100% of total SCHIP enrollment (in
two states). Among the five states that reported a majority
of total SCHIP enrollees being ages 13 through 18,
four were Medicaid-expansion-only states.46
121 The Future of Children
Family income eligibility
thresholds as a
percentage of the federal
poverty level (FPL)
Between 100% and
185% of the FPL (12 states)
Up to but not over
200% of the FPL (26 states,
including DC)
Between 200% and
250% of the FPL (6 states)
Over 250% of the FPL
(7 states)
Figure 2
Medicaid and SCHIP Eligibility for Adolescents under Age 19,
Maximum Income Thresholds as of September 30, 2001
Note: In Vermont, 18-year-olds were eligible if family income was up to but not over 225% of the FPL. In Nevada, 18-year-olds were not eligible based on family income alone.
Source: Analysis of approved Medicaid and SCHIP plans and amendments; conversations with state officials.
WA
OR
ID
MT
CA
AK
HI
NV
UT
AZ
NM
CO
WY
ND
SD
NE
KS
OK
TX
LA
AR
MO
IL
IA
MN
WI
MI
IN
OH
WV
KY
TN
MS AL GA
FL
SC
NC
VA
PA
NY
ME
NH
VT
MA
RI
CT
NJ
DE
MD
DC
Volume 13, Number 1
Benefits Available to Adolescents
Once adolescents enroll in Medicaid or SCHIP, their
access to particular benefits may vary, depending on the
state in which they live and the type of program for which
they are eligible. The Medicaid benefit package includes
a broad range of mandatory and optional services.47
However, for children and adolescents under age 21, all
mandatory and optional Medicaid services must be made
available by a state if medically necessary.48 Nevertheless,
states are allowed to impose initial limits on the amount,
duration, and scope of a particular benefit?such as mental
health services?and adolescents may have to overcome
such limits to obtain all the services they need.
Also, states may be less generous to adolescents than to
younger children, such as in establishing the frequency of
required comprehensive health assessments, or screenings,
in Medicaid.
The scope of benefits available in a state?s SCHIP program
depends on the type of program that was created?
that is, Medicaid expansion, combination, or separate
SCHIP program (see the article by Wysen, Pernice, and
Riley in this journal issue). Benefits for adolescents in
Medicaid expansion SCHIP must meet the requirements
for Medicaid. Benefits for adolescents in a state-designed
SCHIP program must meet minimum criteria, but they
can be more generous. Uniform data about the range of
services offered to adolescents under state-designed
SCHIP programs are not readily available, although
some state-by-state data about specific benefits suggest
that states vary with respect to preventive health services,
reproductive health services, substance-abuse and mental
health services, dental services, and the breadth and
depth of the benefit package for adolescents with special
health care needs.49
122
Brindis, Morreale, and English
Source: Analysis of data provided by the Centers for Medicare and Medicaid Services (CMS), Center for Medicaid and State Operations, Family and Children?s Health Program
Group, August 2002. Data based on an unduplicated count of children and adolescents enrolled in SCHIP during Fiscal Year 2001. These figures do not include missing data (not
reported to CMS) from Alabama (Medicaid expansion data) and Illinois (all data).
Figure 3
Enrollment in SCHIP by Program Type and Age Group, Fiscal Year 2001
Medicaid Expansion SCHIP Enrollees State-Designed SCHIP Enrollees
Under Age 6
Ages 6 through 12
Ages 13 through 18
Under Age 6
Ages 6 through 12
Ages 13 through 18
16%
46%
38%
27%
28%
45%
Health Care Needs of Adolescents
Improving Health Care for Adolescents
through Public Health Insurance Programs
Even though health insurance?whether private or public?
plays a critical role in adolescents? access to health
care services, it does not guarantee that adolescents will
actually receive the services they need to assure their overall
health. A number of significant barriers, both financial
and nonfinancial, prevent young people from receiving
needed care (see Box 1).
To improve adolescent health, states must respond to
adolescents? barriers to care and establish systems and
provider networks that are available, accessible, and
appropriate for this population. To aid states in such
efforts, the Society for Adolescent Medicine has compiled
a list of criteria for evaluating access to quality care
for adolescents (see Box 2).
Insurance coverage is an essential part of access to care,
and Medicaid and SCHIP provide states with an
123 The Future of Children
Box 1
Barriers to Health Care for Adolescents
Shortage of providers trained in adolescent health. Few clinicians
specialize in adolescent health, and most medical staff
are inadequately trained to recognize health problems whose
symptoms may be primarily psychosocial instead of physical.
Although most adolescent medicine specialists are trained as
pediatricians, internists and family physicians reflect the most
common pathways to care for adolescents.
Inadequate provider reimbursement/low provider participation.
Reimbursement and capitation rates for providers serving
children and adolescents are significantly lower for public insurance
than for private insurance. In addition, delays in receiving
payment from public insurance create a strong disincentive for
health care providers to serve publicly insured adolescents.
Limited insurance coverage. Health insurance policies (both
public and private) often sharply limit or do not cover visits for
preventive care, mental health services, substance-abuse treatment,
dental health, and other needed care.
Focus on acute, medical care. The health care system has traditionally
emphasized the treatment of physical problems rather
than health promotion and disease prevention, including mental
health care. Adolescents could benefit significantly from preventive
and primary care services that integrate their physical
and psychosocial needs, such as screening, education, and
anticipatory guidance to prevent and/or ameliorate risk-taking
behaviors that place adolescents at risk for poor health.
Fragmentation. Most teenagers and their families find navigating
the complex and rapidly changing health care system difficult.
Most young people are ill-prepared to understand how to
access health services, have limited knowledge regarding their
eligibility for diverse programs, and have few skills with which
to recognize and anticipate their own needs for health services
or to advocate for their own needs.
Confidentiality. Without confidentiality protections, some adolescents
will forgo care for such issues as pregnancy, sexually transmitted
diseases, or substance abuse. Assurances of
confidentiality have been found to increase adolescents? willingness
to disclose information, report truthfully, and consider a
return visit.
Transportation/inconvenient hours. Most teenagers have to
rely on their parents and/or public transportation to reach health
care providers, yet few physicians and community health clinics
have scheduled their locations or hours of service to accommodate
adolescents? needs. Long waits to obtain an appointment
and/or long waiting times at the provider site may deter adolescents
even more than adults.
Cost. Even very low co-payments may discourage adolescents
and their families from initiating preventive or primary care visits.
Families with low incomes may also struggle with premiums and
deductibles required by employers, state-sponsored/subsidized
programs, and/or private insurance policies.
Volume 13, Number 1
unprecedented opportunity to improve health care for
adolescents. Yet, much work remains to ensure that adolescents
actually enroll in and benefit from public insurance
programs. This work includes addressing gaps in
eligibility, improving outreach and enrollment, offering a
broad range of services, and assuring confidentiality.
Addressing Gaps in Eligibility
Despite recent progress in making more adolescents eligible
for public health coverage, gaps in eligibility remain.
Some groups of adolescents, including many legal immigrant
youth, adolescents who are exiting state custody,
and older adolescents, are particularly vulnerable, either
because they are not eligible for public health coverage
under current federal or state rules or because they are
not identified or screened for eligibility.
Coverage for Legal Immigrants
As described in the article by Lessard and Ku in this journal
issue, numerous studies have shown that immigrant
families have significant health care needs, yet are more
likely than others to lack health insurance and face
numerous barriers to accessing health services. For example,
the 1996 federal welfare law (the Personal Responsibility
and Work Opportunity Reconciliation Act of 1996)
substantially restricted many immigrants? eligibility for
public benefits, including Medicaid and later SCHIP.50
While efforts to address the unique health care needs of
immigrant families must include a diverse array of strategies,
addressing legal and policy barriers to care and coverage
is of critical importance in serving adolescents
within this population.
At a minimum, to help ensure coverage for legal immigrant
adolescents:
Congress should enact legislation that permits states to
expand eligibility for Medicaid and SCHIP to immigrants
who are lawfully present in this country.
Coverage for Adolescents Leaving State Custody
Each year, as many as 20,000 young people age 16 or
older leave the foster care system and are expected to live
independently.51,52 Most of these young people lack
familial, financial, and other support, and many have seri-
124
Brindis, Morreale, and English
Box 2
The Society for Adolescent Medicine?s Criteria of Assessing Adolescent Care
Availability: Age-appropriate services and trained health care
providers must be present in every community.
Visibility: Health services for adolescents must be clearly recognizable
and convenient and should not require extensive or complex
planning by adolescents or their parents.
Quality: Health professionals treating adolescents should demonstrate
a basic level of competence with adolescents, who in turn
should feel satisfied with the care they receive.
Confidentiality: Adolescents should be encouraged to involve their
families in health decisions, but confidentiality must be assured.
Affordability: Public and private health insurance programs must
provide adolescents with both preventive and other additional
services to decrease morbidity and mortality and to promote positive
health behaviors.
Flexibility: Providers, services, and delivery sites must consider
the cultural, ethnic, and social diversity among adolescents.
Coordination: Service providers must ensure that comprehensive
services are available to adolescents.
Source: Klein, J., Slap, G.B., Elster, A.B., and Schonberg, K.B. Access to health care for adolescents: A position paper for the Society for Adolescent Medicine. Journal of
Adolescent Health (1992) 13(2):162?70.
Health Care Needs of Adolescents
ous unmet physical and mental health needs.53 Although
relatively small in number, this is an unusually vulnerable
group of young people in terms of health status, likelihood
of having insurance, and access to care.54 As
described previously, the Foster Care Independence Act
of 1999 (FCIA) included a new option for states to
expand Medicaid coverage to age 21 for young people
who were in foster care on their eighteenth birthdays.
Unfortunately, by July 2002, only eight states had enacted
or implemented this option, although several others
had at least considered doing so.
While the new FCIA Medicaid expansion option is critically
important, it does have limitations. For example, it
does not provide the opportunity to expand coverage to
adolescents who leave the foster care system before age
18, even though they, too, may be expected to live independently.
In addition, approximately 42,000 adolescents
age 16 and older depart the foster care system every year
and either reunite with their parents, go to live with other
relatives, are transferred to the custody of another agency,
or run away.55 Significant numbers of these adolescents are
likely to be eligible for Medicaid or SCHIP on the basis of
income, but are not systematically screened for eligibility
when they leave the foster care system.56
Young people transitioning from the juvenile justice system
also have significant health problems and face
numerous barriers to obtaining health care. Each year in
the United States, hundreds of thousands of youth are
held in the custody of the juvenile justice system at the
state and local levels.57 For example, the National Center
for Juvenile Justice reported that nearly 106,000 juvenile
offenders were held in residential placement facilities during
a one-day census count in 1997.58 These youth
included juveniles who were under age 21, had been
charged with or adjudicated by a court for committing an
offense, and were in residential placement because of that
offense. Annual numbers reveal that in 1993, more than
800,000 youth were held in short- and long-term facilities
in the United States59 and that these young people
were disproportionately members of racial and ethnic
minority groups.60,61
The juvenile population is characterized by a wide variety
of pressing health problems, including behavioral health
125 The Future of Children
Volume 13, Number 1
problems and acute and chronic medical conditions.62,63
In particular, youth in the juvenile justice system experience
significant mental health problems.64 These young
people often receive inadequate health care, especially
mental health care, in juvenile justice custody,65?67 and
their health problems are likely to persist when they leave
state custody. Although while they are incarcerated, many
of them cannot receive Medicaid or SCHIP coverage;
when they exit state custody, most would be eligible for
one of these programs.
To help ensure coverage for vulnerable adolescents leaving
state custody:
States that have not already done so should expand
Medicaid eligibility to include young people who exit
the foster care system at age 18 or thereafter.
States should screen all young people exiting the juvenile
justice and child welfare systems for Medicaid and
SCHIP eligibility.
Coverage Based on Age and Income
Despite the recent expansions of Medicaid and SCHIP
coverage, millions of poor and low-income adolescents
remain uninsured. Many of these adolescents are already
eligible for one of these programs, but simply are not
enrolled. Others live in states that have not raised their
SCHIP eligibility levels as high as permitted under the
federal statute, and others do not qualify because they are
in families with incomes that exceed the federal limits, or
they are older than age 18.
According to the latest data available from the U.S. Census
Bureau, more than 5.7 million children and adolescents
under age 19 in families with incomes at or below
200% of the FPL were uninsured during 2001,68 even
though based on family income, virtually all of these individuals
could have been eligible for Medicaid or SCHIP.
(See the article by Holahan, Dubay, and Kenney in this
journal issue.)
Older adolescents, those age 18 through 24, are less likely
to have health insurance than those in any other age
group. According to the U.S. Census Bureau, 28% of
youth age 18 through 24 were uninsured during 2001
(compared with 12% of children and adolescents under
age 18, 17% of persons age 25 through 64, and less than
1% of persons age 65 and older).69 As with other age
groups, rates of uninsurance are higher among older adolescents
who are poor?nearly one-half (46%) of poor
adolescents age 18 through 24 were uninsured during
2001. The 107th Congress considered several bills that
would have begun to address the eligibility gaps that
remain for older adolescents and those in families with
incomes above 200% of the FPL, but did not enact any
of these bills before it adjourned.70
To help ensure coverage for low-income adolescents:
States that have not already done so should expand
Medicaid and SCHIP to all children and adolescents
in families with incomes up to 200% of the FPL, or
the highest level permitted (given their pre-SCHIP
eligibility rules).
The federal government should permit states to expand
Medicaid and SCHIP eligibility to older adolescents
(under age 24) and to children and adolescents in families
with incomes above 200% of the FPL.
Outreach and Enrollment
To increase the enrollment of eligible children in public
health insurance programs, a wide variety of outreach
strategies have been implemented. (See the article by
Cohen Ross and Hill in this journal issue.) Little of this
activity has specifically targeted adolescents,71 however.
There is a critical need to evaluate which approaches are
most likely to reach adolescents generally and which are
most likely to reach particular subpopulations of youth
who are at increased risk of health problems and access
barriers. Meanwhile, a number of outreach and enrollment
strategies have been recommended for adolescents.
72 These include:
Providing outreach and adolescent-oriented written
materials at sites frequented by young people, such as
school-based health centers, family planning and sexually
transmitted infection clinics, adolescent medicine
clinics, county health departments, high schools,
Job Corps sites, summer job programs, recreation
centers and after-school programs, movie theaters,
and malls.
Developing outreach materials and strategies to reach
special populations of adolescents, such as runaway and
homeless youth, pregnant and parenting adolescents,
adolescents in immigrant families, adolescents with spe-
126
Brindis, Morreale, and English
Health Care Needs of Adolescents
cial health care needs, and adolescents eligible for other
publicly funded programs.
Training adolescents and young adults to conduct
outreach and staff speakers? bureaus and teen telephone
lines.
Teaching enrollment brokers, contractors, health care
workers, and EPSDT workers and other staff at out-stationed
and presumptive eligibility sites about adolescent
health and the importance of reaching this population.
To effectively reach and enroll adolescents who are eligible
for Medicaid and SCHIP:
States should work with a broad array of service organizations,
agencies, schools, and health care providers to
develop, implement, and evaluate outreach and marketing
strategies targeted to adolescents (including special
populations) and their families.
Strategies should be designed to provide information to
adolescents about accessing health services, including
information about finding adolescent-oriented providers,
setting up appointments, co-payment requirements,
grievance options, and the importance of bringing insurance
cards to appointments.
Offering a Broad Range of Services
Adolescents require a broad range of health care services
to address their multiple needs. Services of particular
importance include preventive services, family planning
and reproductive health services, mental health and substance-
abuse services, dental care, and services related to
chronic illnesses or disabilities.73 Medicaid and SCHIP
both offer opportunities to ensure the provision of these
services for adolescents.
Preventive Services
Preventive services represent a key set of benefits in Medicaid
and SCHIP, because many common health problems
faced by adolescents are preventable. The rapid developmental
changes that occur in adolescence necessitate frequent
health assessments in order to identify new health
issues and risk behaviors early. Medicaid requires states to
establish a schedule for comprehensive health assessments
in consultation with professional medical and dental organizations
involved in child health care,74 and there is broad
consensus among professional groups that annual health
assessments for adolescents are needed.75
In Medicaid, EPSDT is the cornerstone of preventive
care for children and could result in the provision of
comprehensive care for adolescents. Yet, full implementation
of EPSDT has not been achieved.76 (See Box 3 for
one example of a state?s effort to enhance delivery of
EPSDT services.) Also, not all states have provided for
annual well-adolescent exams in their state-designed
SCHIP programs.
To provide for annual well-adolescent visits consistent with
the most current recommendations for adolescent care:
States should update their EPSDT periodicity schedules
and ensure that all health plans and providers are using
the updated schedules.
States with separate (non-Medicaid) SCHIP programs
should incorporate requirements for annual comprehensive
well-adolescent evaluations into their benefit packages.
States should ensure that their Medicaid and SCHIP
programs cover appropriate preventive services for adolescents
in accordance with the most current guidelines.
Family Planning and Reproductive Health Services
Among adolescents, high rates of unintended pregnancy
and sexually transmitted infection (including HIV) make
access to family planning and reproductive health services
critical. A broad range of federal programs, including
Medicaid and SCHIP, can help states meet adolescents?
needs for reproductive health services. In Medicaid and
Medicaid expansion SCHIP, family-planning services are
a mandatory and confidential benefit. In state-designed
SCHIP programs, states may include family-planning
services as a benefit. Recent data indicate that although
most states have provided coverage for reproductive
health services for adolescents in their SCHIP programs,
fewer require providing adolescents with information
about the full range of reproductive health services or
127 The Future of Children
Many adolescents will seek health care services?particularly for
such issues as pregnancy, sexually transmitted infections, or
substance abuse?only if they can receive services confidentially.
Volume 13, Number 1
how to access care.77 In addition, although many laws
protect the confidentiality of adolescents (as discussed
later), few states report guaranteeing confidentiality.78
To ensure adolescents? access to essential family-planning
services:
States should ensure that adolescents enrolled in Medicaid
and SCHIP are informed of the family-planning
services available to them and how to access them.
Mental Health and Substance-Abuse Services
High rates of suicide, depression, and substance abuse in
adolescents79 suggest that many teens need access to mental
health and substance-abuse services. Although Medicaid
and SCHIP provide the possibility of broad coverage
for mental health and substance-abuse services, numerous
limitations exist, such as high cost sharing and restrictions
on numbers of outpatient visits per year, numbers of inpatient
days permitted, and the types of providers who can
deliver services and be reimbursed.80?83 While these limitations
generally also apply to younger children and adults,
they are likely to have greater significance for adolescents:
During this developmental period, many behaviors and illnesses
that require mental health services?such as drug
use, depression, and eating disorders?have their onset.
Many adolescents could be helped by receiving preventive
mental health services before emotional or behavioral
problems become severe. But often, services are
not available through Medicaid, SCHIP, or private
insurance without a diagnosis. Nevertheless, some states
are beginning to adopt innovative approaches to
increase adolescents? access to mental health and substance-
abuse services,84 and at least one state, North
Carolina, has made a significant effort to address these
problems (see Box 4).
128
Brindis, Morreale, and English
Box 3
Spotlight on Preventive Health Services?EPSDT in Massachusetts
Massachusetts? Medicaid agency, the Division of Medical Assistance
(DMA), has taken a number of steps to improve the delivery
of preventive services to Medicaid-eligible adolescents.
These steps include:
Forming a task force of state agency staff, health care providers,
representatives of managed care plans, and advocates to identify
barriers and develop strategies for improving adolescents?
access to care.
Adopting new Early and Periodic Screening, Diagnosis, and Treatment
(EPSDT) regulations and updating the agency?s periodicity
schedule to specify annual visits for adolescents through age
20.a DMA expects adherence to the annual exam requirement in
both its managed care and fee-for-service Medicaid programs,
and DMA reimburses its Medicaid providers accordingly.
Providing annual visits for adolescents enrolled in the statedesigned
component of the state?s SCHIP program.
Publicizing the new requirements to health care providers. For
example, the state sent a letter to providers on American Academy
of Pediatrics (AAP) letterhead, signed by the chair of the
AAP committee that developed the schedule and the chair of the
Massachusetts chapter of the AAP. The state put information in
the AAP news, the newsletter for community health centers, and
its own quarterly letter to primary care providers, and also held
trainings on the new schedule.
a The EPSDT periodicity schedule is consistent with AAP guidelines, Guidelines for Adolescent Preventive Services (GAPS), and Bright Futures, as well as with the Medicaid
HEDIS indicator that calls for annual comprehensive well-adolescent exams. It is also reflected in a set of guidelines endorsed by the Massachusetts Health Quality Partners,
a broad group composed of state health agencies including DMA, professional medical societies, hospitals, medical schools, and numerous health plans and insurers.
Sources: Transmittal letter ALL-99: Appendix W?EPSDT services: Medical protocol and periodicity schedule. Commonwealth of Massachusetts, Division of Medical
Assistance, May 14, 2001; Massachusetts Health Quality Partners. MHQP Guidelines: Pediatric Preventive Care Recommendations 2001. Available online at http://
www.mhqp.org/PediatricRec.pdf; and 130 Code of Massachusetts Regulations ?? 450.142, 450.145, and 450.150 (LEXIS 2002).
Health Care Needs of Adolescents
To address the mental health and substance-abuse problems
of adolescents:
States should include coverage in their Medicaid and
SCHIP programs for a limited number of preventive
mental health visits without a diagnosis being required.
States should include coverage in their Medicaid and
SCHIP programs for care coordination to help families
and primary care providers integrate medical care, mental
health care, substance-abuse treatment, and social
services for adolescents.
Dental Care
Dental and oral health problems are particularly severe
for adolescents of all races and ethnic groups who live in
poverty, compared with higher-income youth.85 For
youth who smoke, tobacco use contributes to significant
oral health problems, and adult gum disease may have its
onset at this time.86 Nonetheless, access to dental care for
adolescents is particularly limited, with lack of insurance
and low family income being major barriers to adolescents?
use of preventive dental care.87
Medicaid provides dental coverage for children and
adolescents, and most non-Medicaid SCHIP programs
provide dental coverage, but many limitations exist
with respect to scope of coverage and cost sharing.88 As
with younger children, even adolescents with insurance
coverage often have difficulty finding providers who
accept Medicaid payments, and they encounter long
waiting lists.89
To help ensure that adolescents receive adequate dental
care:
States should implement comprehensive strategies to
increase adolescents? access to dental services in Medicaid
and SCHIP.
129 The Future of Children
Box 4
Spotlight on Mental Health Benefits?North Carolina
In 2000, North Carolina expanded access to mental health
benefits for children and adolescents covered by its public
health insurance programs by improving the coverage of preventive
mental health services and broadening the scope of
providers who may bill Medicaid for their services.
North Carolina now allows up to six visits to specified mental
health and substance-abuse providers without a diagnosis of
mental illness. This policy allows adolescents to receive preventive
mental health and substance-abuse services without being
formally ?labeled? or diagnosed with a psychiatric disorder. This
policy applies to Health Choice, North Carolina?s state-designed
non-Medicaid SCHIP program; Health Check, the state?s Medicaid
program for children; and the state employees benefit program,
on which the Health Choice benefit package is based.
In addition, Medicaid policy in North Carolina has been subsequently
amended to expand opportunities for a broader range of
health care professionals?such as licensed clinical social workers,
master?s-level psychologists, and nurse practitioners with
specialized training?to bill for their services. North Carolina now
permits these mental health professionals who are practicing
independently to enroll directly as Medicaid providers and to bill
for services delivered in their offices.
Like many other states, North Carolina is experiencing severe
budgetary crises, including crises in Medicaid and SCHIP. The
extent to which these crises will impede implementation
of North Carolina?s preventive mental health expansion is not
yet known.
Sources: Division of Medical Assistance, North Carolina Department of Health and Human Services. Medicaid Bulletin (June 2000):13; and Foy, J. North Carolina Pediatric
Society task force on mental health care access, mental health task force reports Medicaid changes to help pediatricians serve children. Unpublished information bulletin
of the North Carolina Pediatric Society. No date.
Volume 13, Number 1
Services for Chronic Illness or Disability
Approximately 1.8 million adolescents ages 12 to 17 experience
some degree of limitation due to chronic conditions, a
prevalence rate that is higher than the rate for younger children.
90 The breadth and depth of the benefit package is particularly
critical for adolescents with chronic illnesses or
disabilities, who often require services of greater variety,
intensity, and duration than do other youth. For example,
these adolescents may need physical, occupational, or speech
therapy, for which benefit limitations are often imposed.91
While Medicaid and SCHIP offer the potential to provide
comprehensive care to adolescents with special health care
needs, services are not always accessible, and important benefits
for this population are sometimes limited.92?94
Assessing the relative effectiveness of Medicaid and statedesigned
SCHIP programs in meeting the needs of adolescents
with chronic illnesses or disabilities is difficult.
State-designed SCHIP programs have greater latitude in
shaping their benefit packages, and the effect varies
among the programs: Some states have elected to limit
the types of benefits important for adolescents with
chronic conditions, but some have chosen to offer an
enriched benefit package for children and adolescents
with special health care needs that is equivalent to the
breadth of the Medicaid benefit package.95 (See the article
by Szilagyi in this journal issue for a more complete
discussion of children with special health care needs.)
To address the needs of adolescents with chronic illnesses
or disabilities:
States should offer an expanded benefit package in
state-designed SCHIP programs for children and adolescents
with chronic illnesses or disabilities.
Assuring Confidentiality
Many adolescents will seek health care services?particularly
for such issues as pregnancy, sexually transmitted
infections, or substance abuse?only if they can receive
services confidentially.96?98 Studies show that assurances
of confidentiality increase adolescents? willingness to disclose
information, report truthfully, and consider a return
visit, and that without confidentiality protection, some
adolescents will forgo care.99,100
Numerous federal and state laws affect the confidentiality
of adolescents? health care information, addressing
issues such as when adolescents may give their own consent
for care and when information is shared with parents.
At the federal level, new medical privacy regulations,
initially issued in late 2000, contain specific requirements
regarding the confidentiality of medical records and
information pertaining to the care of minors, including
adolescents who are under age 18.101 These rules, which
went into effect in 2001 and were modified in August
2002,102 stipulate that when minors can receive health
care based on their own consent?that is, without
parental consent?they can exercise most of the privacy
rights provided under the federal privacy regulations.103
However, the rules give states greater latitude to determine
the extent of privacy protections for minors than for
adults and defer to ?state or other law? on the question
of when otherwise protected information may or must be
disclosed to parents. The federal Title X Family Planning
Program and the federal confidentiality regulations for
drug and alcohol programs also include strong confidentiality
protections for adolescents who seek treatment on
their own.104 Finally, both Medicaid and SCHIP include
some confidentiality protections that should extend to
adolescents receiving services.105
At the state level, every state has laws that control the
confidentiality of medical information and records106 and
allow minors to give their own consent for health care in
specific circumstances.107 The minor consent laws generally
are based either on the status of the adolescent minor
or on the services being sought.108 Overall, every state
offers some confidentiality protections to adolescents
who are minors (under age 18), while adolescents age 18
or older generally receive the same confidentiality protections
as other adults.
To ensure that adolescents who are served in Medicaid
and SCHIP are able to access essential services on a confidential
basis:
The federal government and states should ensure that
health plans and health care providers adopt medical
record, billing, and laboratory procedures that protect
the confidentiality of services provided to adolescents.
States and health plans should provide health care
providers and enrollees with specific information about
minor consent and confidentiality protections that exist
for adolescents.
130
Brindis, Morreale, and English
Health Care Needs of Adolescents
Quality and Performance Measurement
Policymakers, purchasers, researchers, health care
providers, and consumers have become increasingly concerned
about the quality of health care provided through
both commercial and publicly funded insurance programs.
109 Considerable progress has been made in recent
years toward developing and testing quality-measurement
strategies and tools related to the care received by
children and adolescents. For example, some qualitymeasurement
tools include items of particular importance
to adolescents, such as adolescent well-care visits;
screening for chlamydia; utilization of mental health services;
screening, counseling, and treatment for substance
abuse and chemical dependency; immunization status;
and counseling for risk behaviors and other issues such as
diet, exercise, and emotional health.110
Nevertheless, only a small number of states have adopted
these measures or items for their Medicaid and SCHIP
programs, and little is currently known about how adolescents
use services in Medicaid and SCHIP or the quality
of services that these programs provide.111 For
example, while every state is collecting quality or performance
data related to SCHIP enrollees? use of health
care services, few states have established performance
goals or strategic objectives for SCHIP that address issues
of particular importance to adolescents. Of the 33 states
that included performance measures related to immunization
status in their Fiscal Year 2001 annual reports for
SCHIP, only 10 reported measuring the immunization
status of adolescents.112 Similarly, while 32 states are collecting
data related to annual well-child visits, only 14
states specifically report collecting data related to annual
well-adolescent visits. Even for measures that are relevant
for all enrollees regardless of age, such as access to a usual
source of care, improving EPSDT screening rates, or
increasing Medicaid and SCHIP enrollment, only a small
number of states are collecting or reporting these findings
by age group, making it impossible to determine if
the programs are serving children and adolescents equally
well or poorly.
To promote a better understanding of how adolescents
use services in Medicaid and SCHIP, and the quality of
services that these programs provide:
The federal government and states should collect, analyze,
and report quality and performance data in a consistent
and uniform way, by appropriate categories
including age group, gender, race, ethnicity, and primary
language.
States working with consumers (including adolescents),
purchasers, health plans, and health care professionals
with expertise in caring for adolescents should adopt
adolescent-specific performance measures designed to
monitor clinical effectiveness, use of services, access,
and satisfaction with care.
Quality assurance and performance assessment should
include measures that focus on health promotion and
prevention, including counseling and screening related
to health-compromising behaviors, unwanted pregnancy
and sexually transmitted infections, diet, weight,
asthma, exercise, depression, and mental health.
States should require that all purchasers, including
Medicaid and SCHIP plans, adhere to the HEDIS
guidelines that are specific to or relevant to the care of
adolescents.
Conclusion
All adolescents, including those with private insurance,
face significant barriers to accessing the care they need.
Whether through insurance or other programs, enhancing
adolescents? access to health care will require the dedication
of a broad array of policymakers, health care
providers, researchers, advocates, and consumers, including
adolescents and their families. While Medicaid and
SCHIP have made a significant impact on adolescents?
access to health services, much remains to be done to
ensure that these programs reach their potential.
The authors gratefully acknowledge the support provided
by the Maternal and Child Health Bureau, Health
Resources and Services Administration, U.S. Department
of Health and Human Services; The David and Lucile
Packard Foundation; and the William T. Grant Foundation.
The views expressed are those of the authors and
not of their respective funders.
131 The Future of Children
Volume 13, Number 1
1. See the article by Holahan, Dubay, and Kenney in this journal issue.
2. Newacheck, P., Brindis, C., Cart, C., et al. Adolescent health
insurance coverage: Recent changes and access to care. Pediatrics
(1999) 104:195?202.
3. Newacheck, P., Hughes, D., and Cisternas, M. Children and
health insurance: An overview of recent trends. Health Affairs
(Spring 1995):244?54.
4. Lieu, T., Newacheck, P., and McManus, M. Race, ethnicity and
access to ambulatory care among US adolescents. American
Journal of Public Health (1993) 83:960?65.
5. U.S. Congress Office of Technology Assessment. Adolescent
health volume I: Summary and policy options. Washington, DC:
U.S. Government Printing Office, 1991.
6. See note 3, Newacheck, et al.
7. Irwin, C., Brindis, C., Holt, K., et al., eds. Health care reform:
Opportunities for improving adolescent health. Arlington, VA:
National Center for Education in Maternal and Child Health, 1994.
8. U.S. Census Bureau, Population Division, Population Projections
Branch. National population projections, summary files. 2002.
Available online at http://www.census.gov/population/www/
projections/natsum-T3.html.
9. Ozer, E., Brindis, C., Millstein, S., et al. America?s adolescents: Are
they healthy? San Francisco: National Adolescent Health Information
Center, University of California, San Francisco, 1998.
10. These organizations include the American Academy of Pediatrics;
the Association of Maternal and Child Health Programs; the
Center for Adolescent Health and the Law; the Maternal and
Child Health Policy Research Center; and the National Adolescent
Health Information Center and Policy Information and
Analysis Center for Middle Childhood and Adolescence of the
University of California, San Francisco.
11. For example, the Forum on Adolescence of the National
Research Council and the Institute of Medicine describe adolescence
as including three developmental phases: early adolescence
(ages 10 through 14), middle adolescence (ages 15 through 17),
and late adolescence (ages 18 through the early 20s). The Society
for Adolescent Medicine includes young people ages 10 through
24 in its definition, and the World Health Organization defines
an adolescent as a person between ages 10 and 19. Forum on
Adolescence, National Research Council and Institute of Medicine.
Risks and opportunities: Synthesis of studies on adolescence.
Washington, DC: National Academy Press, 1999; Adolescent
medicine?a position statement of the Society for Adolescent
Medicine. Journal of Adolescent Health (1995) 16:413; World
Health Organization. Adolescent health and development. 2000.
Available online at http://www.who.int/child-adolescent-health/
OVERVIEW/AHD/adh_over.htm.
12. Kann, L., Warren, C., Harris, W., et al. Youth risk behavior survey?
United States, 1997. Atlanta: Surveillance and Evaluation
Research Branch, Division of Adolescent and School Health,
Centers for Disease Control and Prevention, 1998.
13. National Center for Health Statistics, Centers for Disease Control
and Prevention. Death: Preliminary data for 2000. October 9,
2001. Available online at http://www.cdc.gov/nchs/data/nvsr/
nvsr49/nvsr49_12.pdf.
14. Weinstein, N.D. Unrealistic optimism about susceptibility to
health problems: Conclusions from a community-wide sample.
Journal of Behavioral Medicine (1987) 10:481?500.
15. For example, Growing Up Smoke Free, a 1994 report by the Institute
of Medicine, urged Congress to increase the federal tax on
tobacco products in light of evidence indicating that children and
adolescents are more price-sensitive than adults. See also Bonnie,
R.J. Tobacco and public health policy: A youth-centered
approach. In Smoking: Risk, Perception and Policy. P. Slovic, ed.
Thousand Oaks, CA: Sage Publications, 2001.
16. English, A., Kapphahn, T., Perkins, J., and Wibbelsman, C.J.
Meeting the health needs of adolescents in managed care. Journal
of Adolescent Health (1998) 22:278?92.
17. Park, J., MacDonald, T., Ozer, E., et al. Investing in clinical preventive
health services for adolescents. San Francisco: Policy Information
and Analysis Center for Middle Childhood and
Adolescence and National Adolescent Health Information Center,
University of California, San Francisco, 2001.
18. See note 9, Ozer, et al.
19. Fox, H., McManus, M., and Reichman, M. Private health insurance
for adolescents: Is it adequate? Journal of Adolescent Health.
In press.
20. The Health Plan Employer Data and Information Set (HEDIS)
was developed by the National Committee for Quality Assurance
(NCQA). For information about HEDIS, see the NCQA Web
site at http://www.ncqa.org/Programs/HEDIS/index.htm.
21. Brindis, C.D., VanLandeghem, K., Kirkpatrick, R., et al. Adolescents
and the State Children?s Health Insurance Program
(SCHIP): Healthy options for meeting the needs of adolescents.
Washington, DC: Association of Maternal and Child Health Programs,
and San Francisco: Policy Information and Analysis Center
for Middle Childhood and Adolescence and National Adolescent
Health Information Center, University of California, San Francisco,
September 1999.
22. English, A., Morreale, M., and Stinnett A. Adolescents in public
health insurance programs: Medicaid and CHIP. Chapel Hill, NC:
Center for Adolescent Health and the Law, December 1999.
23. American Academy of Pediatrics. Section report: Improving the
implementation of State Children?s Health Insurance Programs
for adolescents, report of an invitational conference sponsored by
the American Academy of Pediatrics, section on adolescent health.
September 26?27, 1999. Pediatrics (April 2000) 105(4):906?12.
24. Fox, H.B., McManus, M.A., and Limb S.J. Access to care for
SCHIP adolescents. Washington, DC: Maternal and Child Health
Policy Research Center for the Kaiser Commission on Medicaid
and the Uninsured, Henry J. Kaiser Foundation, December 2000.
25. See the article by Holahan, Dubay, and Kenney in this journal issue.
26. See the article by Mann, Rowland, and Garfield in this journal issue.
27. Perkins, J., and Somers, S. An advocate?s guide to the Medicaid
program. Los Angeles: National Health Law Program, June 2001.
28. Kaiser Commission on Medicaid and the Uninsured. Medicaid
?mandatory? and ?optional? eligibility and benefits. Washington,
DC: KCMU, Henry J. Kaiser Family Foundation, June 2001.
29. The Medicare Catastrophic Coverage Act of 1988 (Public Law
132
Brindis, Morreale, and English
ENDNOTES
Health Care Needs of Adolescents
100-360) mandated coverage of pregnant women and infants in
families with incomes up to 100% of the FPL. The Omnibus
Budget Reconciliation Act of 1989 (Public Law 101-239) mandated
coverage for pregnant women and children under age 6 in
families with incomes up to 133% of the FPL. The Omnibus Reconciliation
Act of 1990 (Public Law 101-508) mandated that
states phase in eligibility for children ages 6 through 18 in families
with incomes up to 100% of the FPL.
30. For the purposes of Medicaid and SCHIP eligibility, family
income is measured as a percentage of FPL, where ?poor? is
defined as 100% of the FPL. FPL refers to the federal poverty
guidelines that the Department of Health and Human Services
issues each year and publishes in the Federal Register. The guidelines
vary by family size and jurisdiction. In 2002, for example,
100% of the FPL for a family of four living in the 48 contiguous
states and the District of Columbia was $18,100. See Office of
the Assistant Secretary for Planning and Evaluation, U.S. Department
of Health and Human Services. The 2002 HHS poverty
guidelines. 2002. Available online at http://www.aspe.hhs.gov/
poverty/02poverty.htm.
31. Social Security Act, Title XIX, 42 U.S.C. ? 1396a(l)(D) and 42
U.S.C. ? 1396a(l)(2)(C) (LEXIS 2002), requires states to phase
in eligibility to children in families with incomes less than or
equal to 100% of the FPL who were born after September 30,
1983 (or, at the option of a state, after any earlier date), and are
between ages 6 and 18.
32. The Foster Care Independence Act of 1999 (Public Law 106-169)
increased federal funds for programs to assist youths in the transition
from foster care to independence and created a new option for
states to expand Medicaid to this vulnerable population.
33. This option, commonly called the ?1902(r)(2) option,? allows
states to use less-restrictive income and resource methodologies
to determine Medicaid eligibility for certain groups. For additional
information, see Center for Medicare and Medicaid Services.
Medicaid eligibility groups and less restrictive methods of determining
countable income and resources. May 11, 2001. Available online
at http://www.cms.gov/medicaid/eligibility/elig0501.pdf.
34. Centers for Medicare and Medicaid Services. MSIS statistical
report for federal Fiscal Year 1999, table 2, Medicaid eligibles?Fiscal
Year 1999, by age group, all states. (National total revised June
25, 2002.) Available online at http://www.cms.gov/medicaid/
msis/99total.pdf.
35. Social Security Act, Title XXI, 42 U.S.C. ? 1397jj(b)(1)(B)(i)
and (ii)(I) (LEXIS 2002), permit states that had previously raised
their Medicaid eligibility levels above 150% of the FPL to extend
SCHIP eligibility to children and adolescents in families with
incomes up to 50 percentage points higher than the state?s Medicaid
eligibility cutoff as of March 31, 1997, for children of the
same age.
36. Social Security Act, Title XXI, 42 U.S.C. ?? 1397jj(b)(1)(C) and
1397jj(b)(4) (LEXIS 2002); and Public Health Service Act, Title
XXV, 42 U.S.C. ? 300gg-91 (LEXIS 2002).
37. Social Security Act, Title XIX, 42 U.S.C. ? 1396d(b) (LEXIS 2002).
38. Morreale, M.C., and English, A. Eligibility and enrollment of
adolescents in Medicaid and SCHIP: Recent progress, current
challenges. Journal of Adolescent Health. In press.
39. See note 38, Morreale and English.
40. See note 38, Morreale and English.
41. See note 38, Morreale and English.
42. Calculation based on data provided by the Center for Medicare
and Medicaid Services (CMS), Center for Medicaid and State
Operations, Family and Children?s Health Program Group,
August 2002. Data do not include missing data (not reported to
CMS) from Alabama and Illinois.
43. See note 38, Morreale and English.
44. Rosenbaum S., and Smith, B. Policy brief #1: State SCHIP design
and the right to coverage. Washington, DC: Center for Health
Services Research and Policy, 2001. Available online at http://
www.gwhealthpolicy.org/brief_1.pdf.
45. Once a state?s SCHIP allotment is exhausted, the state receives
payments at the regular Medicaid matching rate. Centers for
Medicare and Medicaid Services. The administration?s responses to
questions about the State Children?s Health Insurance Program.
2002. Available online at http://www.cms.hhs.gov/schip/
qandaintro.asp.
46. See note 42, Center for Medicare and Medicaid Services.
47. For additional information, see Centers for Medicare and Medicaid
Services. Medicaid Services. 2002. Available online at
http://www.cms.gov/medicaid/mservice.asp; and Centers for
Medicare and Medicaid Services. Medicaid and EPSDT. 2002.
Available online at http://www.cms.gov/medicaid/epsdt/
default.asp.
48. Social Security Act, Title XIX, 42 U.S.C. ? 1396d(r) (LEXIS
2002).
49. See the article by Szilagyi in this journal issue.
50. Prior to passage of the Personal Responsibility and Work Opportunity
Reconciliation Act of 1996 (Public Law 104-193, also known
as PRWORA), immigrants who were in the United States lawfully
were generally eligible for Medicaid on the same basis as citizens.
With the enactment of PRWORA, Medicaid eligibility for immigrants
is now based on citizenship status rather than legal status.
See Fremstad, S. Immigrants and welfare reauthorization. Washington,
DC: Center on Budget and Policy Priorities, February
2002; and Centers for Medicare and Medicaid Services. State Medicaid
manual. 2002. Available online at
http://www.cms.gov/manuals/pub45/pub_45.asp.
51. U.S. Department of Health and Human Services, Administration
for Children and Families, Children?s Bureau. The AFCARS report:
Interim FY 2000 estimates as of August 2002. Available online at
http://www.acf.hhs.gov/programs/cb/publications/afcars/
report7.pdf.
52. U.S. General Accounting Office. Foster care: Effectiveness of independent
living services unknown. Washington, DC: GAO/Health,
Education and Human Services Division, November 1999.
53. English, A., and Grasso, K. The Foster Care Independence Act of
1999: Enhancing youth access to health care. Clearinghouse
Review/Journal of Poverty Law (July?August 2000):217?32.
54. English, A., Morreale, M.C., and Larsen, J. Access to health care
for youth leaving foster care: Medicaid and SCHIP. Journal of
Adolescent Health. In press.
133 The Future of Children
Volume 13, Number 1
55. See note 51, U.S. Department of Health and Human Services.
56. See note 54, English, et al.
57. Snyder, H.N., Sickmund, M., and Bilchik, S. Juvenile offenders
and victims: 1999 National report. National Center for Juvenile
Justice, Office of Juvenile Justice and Delinquency Prevention,
September 1999. Available online at http://www.ncjrs.org/html/
ojjdp/nationalreport99/index.html.
58. See note 57, Snyder, et al.
59. Austin, J., Krisberg, B., and DeComo, R. Juveniles taken into custody:
Fiscal Year 1993. Washington, DC: Office of Juvenile Justice
and Delinquency Prevention, U.S. Department of Justice, 1995.
60. See note 57, Snyder, et al.
61. Soler, M. Health issues for adolescents in the justice system.
Journal of Adolescent Health. In press.
62. Council on Scientific Affairs, American Medical Association.
Health status of detained and incarcerated youths. Journal of the
American Medical Association (1990) 263:987?91.
63. Society for Adolescent Medicine. Health care for incarcerated
youth: Position paper of the Society for Adolescent Medicine.
Journal of Adolescent Health (2000) 27:73?75.
64. See note 61, Soler.
65. See note 62, Council on Scientific Affairs.
66. See note 63, Society for Adolescent Medicine.
67. See note 61, Soler.
68. U.S. Census Bureau. Current population survey annual demographic
survey, March supplement, detailed health insurance (P60)
Package. Available online at http://ferret.bls.census.gov/macro/
032002/health/h10_000.htm.
69. U.S. Census Bureau. Health insurance coverage: 2001. September
2002. Available online at http://www.census.gov/prod/2002pubs/
p60-220.pdf.
70. For example, several bills would allow states to provide Medicaid
and SCHIP coverage through age 22 or 24 (rather than 19)
and/or to extend coverage to children and adolescents in families
with incomes up to 250% or 300% of the FPL. See the Start
Healthy, Stay Healthy Act of 2001, S. 1016; the SCHIP
Enhancement Act of 2001, S. 1266; the Family Care Act of
2001, H.R. 2630/S. 1244; the Leave No Child Behind Act of
2001, H.R. 1990/S. 940; the Dylan Lee James Act, H.R.
600/S. 321; and the MediKids Health Insurance Act of 2002,
H.R. 1733/S. 827.
71. See note 22, English, et al.
72. See note 21, Brindis, et al.; note 22, English, et al.; and note 23,
American Academy of Pediatrics.
73. See note 22, English, et al.
74. See note 48, Social Security Act.
75. See note 17, Park, et al. However, although professional guidelines
for clinical preventive services recommend annual health
assessments for adolescents, only 16 of 47 states responding to a
recent survey specify the recommended annual visits for adolescents
in their EPSDT periodicity schedules. See McNulty, M.
Medicaid, managed care and adolescent health: State prevention
policies. Rochester, NY: University of Rochester. Monograph in
press.
76. See General Accounting Office. Medicaid: Stronger efforts needed
to ensure children?s access to health screening services. Washington,
DC: Government Printing Office, July 2001; Olson, K., Perkins,
J., and Pate, T. Children?s health under Medicaid: A national
review of Early and Periodic Screening, Diagnosis and Treatment.
Los Angeles: National Health Law Program, 1998; and Stinnett,
A., Perkins, J., and Olson, K. Children?s health under Medicaid: A
national review of Early and Periodic Screening, Diagnosis and
Treatment?1997?1998 update. Los Angeles: National Health
Law Program, 2001.
77. Gold, R.B., and Sonfield, A. Reproductive health services for
adolescents under the State Children?s Health Insurance Program.
Family Planning Perspectives (March/April 2001)
33(2):81?87.
78. National Conference of State Legislatures. Providing reproductive
health services for adolescents: State options. No date. Available
online at http://www.ncsl.org/programs/health/forum/
pub6768.htm.
79. U.S. Department of Health and Human Services. Mental health:
A report of the surgeon general. Rockville, MD: DHHS, Substance
Abuse and Mental Health Services Administration, Center for
Mental Health Services, National Institutes of Health, National
Institute of Mental Health, 1999.
80. Stateserv, Health Policy Tracking Service. Table 5. Mental health
benefits in non-Medicaid SCHIP plans, September 30, 2000, and
Table 6. Substance abuse treatment benefits in non-Medicaid
SCHIP plans, September 30, 2000. May 10, 2001. Available
online at http://stateserv.hpts.org.
81. Gehshan, S. Substance abuse treatment in State Children?s Health
Insurance Programs. Denver: National Conference of State Legislatures
(February 2001). Available online at http://www.ncsl.org/
programs/health/forum/saschip.htm.
82. See note 24, Fox, et al.
83. Howell, E.M., Buck, J.A., and Teich, J.L. State report: Mental
health benefits under SCHIP. Health Affairs (November/December
2000) 19(6):291?97.
84. See note 22, English, et al.; and note 21, Brindis, et al.
85. U.S. Department of Health and Human Services. Oral health in
America: A report of the surgeon general. Rockville, MD: DHHS,
National Institutes of Dental and Craniofacial Research, National
Institutes of Health, 2000.
86. See note 85, U.S. Department of Health and Human Services.
87. Yu, S.M., Bellamy, H.A., Schwalberg, R.H., and Drum, M.A.
Factors associated with use of preventive dental and health services
among U.S. adolescents. Journal of Adolescent Health (2001)
29(6):395?405.
88. Stateserv, Health Policy Tracking Service. Table 4. Dental benefits
in non-Medicaid SCHIP plans, September 30, 2000. May 10, 2001.
Available online at http://stateserv.hpts.org.
89. See note 24, Fox, et al.
90. Newacheck, P.W., and Halfon, N. Prevalence and impact of disabling
chronic conditions in childhood. American Journal of
Public Health (1998) 88(4):610?17, Table 1.
91. Fox, H.B., Graham, R.R., McManus M.A., and Chen, C.Y. An
analysis of states? CHIP policies affecting children with special
health care needs. Washington, DC: Maternal and Child Health
Policy Research Center, 1999.
92. Fox, H.B., McManus, M.A., and Limb, S.J. Access to care for
SCHIP children with special health care needs. Washington, DC:
134
Brindis, Morreale, and English
Health Care Needs of Adolescents
Maternal and Child Health Policy Research Center for the Kaiser
Commission on Medicaid and the Uninsured, Henry J. Kaiser
Family Foundation, December 2000.
93. Rosenbaum, S., Shaw, K., and Sonosky, C. Policy Brief #3: Managed
care purchasing under SCHIP: A nationwide analysis of freestanding
SCHIP contracts. Washington, DC: Center for Health
Services Research and Policy, George Washington University,
December 2001.
94. Stateserv, Health Policy Tracking Service. Table 3. Optional benefits
and services in non-Medicaid SCHIP plans, September 30, 2000,
and Table 7. Selected benefits for children with special health care
needs (CSHCN) in non-Medicaid SCHIP plans, September 20,
2000. May 10, 2001. Available online at http://stateserv.hpts.org.
95. See note 92, Fox, et al.
96. Gans, J., ed. Policy compendium on confidential health services for
adolescents. Chicago: American Medical Association, 1994.
97. American Medical Association, Council on Scientific Affairs.
Confidential health services for adolescents. Journal of the American
Medical Association (1993) 269:1420?24.
98. Society for Adolescent Medicine. Confidentiality for adolescents:
Position paper of the Society for Adolescent Medicine. Journal
of Adolescent Health (1997) 21:408?15.
99. Ford, C.A., Millstein, S., Halpern-Felsher, B., and Irwin, C.
Influence of physician confidentiality assurances on adolescents?
willingness to disclose information and seek future health care.
Journal of the American Medical Association (1997)
278:1029?34. See also Cheng, T.L., Savageau, J., Sattler, A., and
DeWitt, T. Confidentiality in health care: A survey of knowledge,
perceptions, and attitudes among high school students. Journal of
the American Medical Association (1993) 269:1404?07.
100. Ford C.A., Bearman, P., and Moody, J. Forgone health care
among adolescents. Journal of the American Medical Association
(1999) 282:2227?34.
101. The Federal Privacy Rule, issued under the Health Insurance
Portability and Accountability Act of 1996, was made final in
December 2000. See Standards for Privacy of Individually Identifiable
Health Information: Final Rule, 65, Federal Register
82461 (28 December 2000), codified at 45 Code of Federal
Regulations Parts 160, 164.
102. Standards for Privacy of Individually Identifiable Health Information:
Final Rule, 67, Federal Register 53182 (14 August
2002).
103. 45 Code of Federal Regulations ? 164.502(g).
104. Public Health Service Act, Population Research and Voluntary
Family Planning Programs, 42 U.S.C. ?? 300 et seq. (LEXIS
2002); 42 Code of Federal Regulations ? 59.11 (LEXIS 2002);
and 42 Code of Federal Regulations ?? 2.1?2.63 (LEXIS 2002).
105. Social Security Act, Title XIX, 42 U.S.C. ? 1396a(a)(7) (LEXIS
2002); 42 Code of Federal Regulations ?? 431.300?431.306;
438.224; 457.1110 (LEXIS 2002).
106. Health Privacy Project. The state of health privacy: An uneven terrain.
Washington, DC: Health Privacy Project, Institute for
Health Care Research and Policy, Georgetown University, 1999.
Available online at http://www.healthprivacy.org/resources/
statereports/contents.html.
107. English, A., Morreale, M.C., Stinnett, A., et al. State minor consent
laws: A summary, 2d ed. Chapel Hill, NC: Center for Adolescent
Health and the Law, 2003. Depending on the state,
minors may be allowed to give their own consent if they are
mature minors, legally emancipated minors, married minors,
minors in the armed forces, minors living apart from their parents,
minors over a certain age, high school graduates, pregnant
minors, or minor parents. Also, depending on the state, they may
be able to consent to one or more services, such as emergency
care, pregnancy-related care, contraceptive services, diagnosis
and treatment of venereal or sexually transmitted infections,
HIV/AIDS testing and/or treatment, treatment or counseling
for drug or alcohol problems, collection of medical evidence or
treatment for sexual assault, inpatient mental health services, or
outpatient mental health services.
108. See note 107, English, et al.
109. See, for example, Institute of Medicine, Committee on Quality of
Health Care in America. Crossing the quality chasm: A new health
system for the 21st century. Washington, DC: National Academy
Press, 2001; Institute of Medicine, Board on Health Care Services.
Envisioning the national health care quality report. Washington,
DC: National Academy Press, 2001; Agency for Health Care
Research and Quality. Child health toolbox: Measuring performance
in child health programs. Uses of performance measurement.
March 2001. Available online at http://www.ahrq.gov/chtoolbx;
and Schmid, M. Health plan performance measurement: What is
it, how it impacts CHIP and Medicaid, and why child advocates
should care. Washington, DC: National Association of Child
Advocates, November 1999.
110. See, for example, the Health Plan Employer Data and Information
Set (HEDIS), developed by the National Committee for Quality
Assurance (see the NCQA Web site at http://www.ncqa.org/
Programs/HEDIS/index.htm); the Young Adults Health Care
Survey developed by the Foundation for Accountability (see the
FACCT Web site at http://facct.org); and Bethell C., Klein J.,
and Peck C. Assessing health system provision of adolescent preventive
services: The Young Adults Health Care Survey. Medical
Care (2002) 39(5):478?90.
111. One study, conducted by the American Public Human Services
Association (APHSA), found that among enrollees of nearly 170
Medicaid managed care plans in 31 states and Puerto Rico, surveyed
in 1999, approximately 29% of adolescents received an annual
well-care visit, compared with 51% of children ages 3 through 6,
and that only a little more than half (51%) of 13-year-old adolescents
received the recommended second dose of measles/
mumps/rubella immunization. See Partridge, L. The APHSA
Medicaid HEDIS database project, report for the third project year
(data for 1999). American Public Human Services Association,
December 2001. Available online at http://www.cmwf.org/
programs/quality/partridge_aphsa_hedis_1999.pdf.
112. Center for Adolescent Health & the Law. Analysis of Title XXI
annual reports from FY 2001. Unpublished 2002.
135 The Future of Children