The 2010 National Health Interview Survey reported that most U.S. children age 17 years and under had excellent or very good health and the adolescent death rate has declined steadily over the last decade.2 Despite these encouraging trends, major disparities still exist among the population. Moreover, the health care needs of adolescents are numerous and complex. The health of young people must be continuously evaluated with continued support for programs that seek to improve their health and well-being. This issue brief will describe how the Affordable Care Act (ACA) and public programs like Medicaid and the Children?s Health Insurance Program (CHIP) can best meet the health needs of low-income adolescents.
Background
Major health problems and concerns
All adolescents need regular check-ups, and most need contraceptive services and STD screenings. Many adolescents need treatment and monitoring for chronic health conditions, including asthma, or behavioral health care services. Adolescents are far less likely than adults to suffer from cardiovascular disease or cancers, but instead have their own problems, some of them life-threatening, from which they suffer disproportionately. These problems, which include poor nutrition, mental and emotional illness, suicide, chronic illness, pregnancy, STDs, and substance use, have been described as ?preventable health conditions with predominantly behavioral and environmental etiologies.?3
Income level and race also play a role in adolescent health status. For example, poor youth tend to have higher rates of pregnancy, STDs, HIV, and substance use than their wealthier counterparts. Health problems are particularly acute for minority youth. Across all adolescent health problem measures, Black and Latino adolescents are disproportionately affected.4
In terms of chronic disease and disability, approximately 2.8 million school-aged children suffer from physical disabilities that limit their ability to do regular schoolwork, create problems in personal care or activities of daily living, and/or require them to use assistive aids.5 Black adolescents are much more likely to suffer serious consequences, including death, from chronic conditions like asthma as compared to White adolescents.6 Furthermore, five times as many foster children (30 percent) as children in the general population suffer from chronic disorders.7
Mental disorders account for approximately 32 percent of all adolescent disabilities, making them the single largest cause of disability among adolescents.8 Approximately 20 percent of adolescents have a diagnosable mental disorder, and major depression affects 5 percent of youth aged 9 to 17 years.9
Understanding the sexual activity and reproductive health of adolescents is crucial to ensuring overall health and well-being. Approximately 47 percent of teenagers report having had sexual intercourse, and 15.3 percent report having had sex with four or more people during their life.10 Nearly half of the 19 million new STDs each year are among young people aged 15-24 years.11
Some notable improvements have occurred in recent years. Between 2006 and 2010, for example, approximately 86 percent of female teens and 93 percent of male teens reported using contraceptives at last sex (up from 71 percent and 82 percent respectively in 1995).12 On the other hand, in 2008, young people aged 13-24 made up about 17 percent of all individuals diagnosed with HIV/AIDS.13
In terms of adolescent pregnancy, each year nearly 750,000 women aged 15-19 become pregnant, with two-thirds of all teen pregnancies occuring among women aged 18-19.14 Although the teen pregnancy rate in the U.S. has declined in the past several years, it is still one of the highest in the developed world. In 2005, New Mexico had the highest teenage pregnancy rate (93 per 1,000), followed by Nevada, Arizona, Texas and Mississippi.15 Approximately 82 percent of teen pregnancies are unplanned, accounting for one-fifth of all unintended pregnancies per year in the United States. In 2008, 59 percent of pregnancies among 15-19 year olds ended in birth, and 26 percent in abortion.16
Adolescents and young adults without health insurance are more likely to have unmet medical needs, to have no usual source of care, and to report fair or poor health.17 Public insurance rates for adolescents are highest for those aged 13 to 14 years, with the rate declining sharply between the ages of 17 and 20 years, likely a result of aging out of public coverage programs like Medicaid.18 Studies have shown that racial and ethnic disparities in coverage are present in adolescents and continue into young adulthood.19 While uninsured rates for children have fallen, eight million children remained uninsured in 2010.20 Poor and low-income children are more likely to be uninsured than their higher income counterparts, as are racial and ethnic minorities as compared to White children.21 Approximately 74 percent of uninsured children live in households below 200 percent of the FPL, and 65 percent of these children are in families with at least one full-time worker but, due to lack of employer coverage or unaffordability, are not able to access employer-sponsored family coverage.22
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1 Thanks to Esther Earbin, 2L at the University of North Carolina at Chapel Hill School of Law, for assistance with this Issue Brief.
2 Barbara Bloom et al., Summary health statistics for U.S. children: National Health Interview
Survey, 2010; Nat?l Center for Health Statistics, 10 Vital Health Stat. 250 (2011); Nan Jiang et al., Health of Adolescents and Young Adults: Trends in Achieving the 21 Critical National Health Objectives by 2010, 49 J. Adolescent Health 124 (2011).
3 David S. Rosen et al., Clinical Preventive Services for Adolescents: Position Paper of the Society for Adolescent Medicine, 21 J. Adolescent Health 203 (1997).
4 Tracy A. Lieu et al., Race, Ethnicity, and Access to Ambulatory Care among U.S. Adolescents, 83 Am. J. Pub. Health 960 (1993); Laurie Emmer, The Impact of Poverty on Adolescent Health, 3 Adolescent Health 2 (2003).
5 Elizabeth M. Ozer et al., Nat?l Adolescent Health Info. Ctr., America?s Adolescents: Are they
Healthy? 13 (1998) [hereinafter NAHIC]; Centers for Disease Control & Prevention, Disabilities Among Children Aged less than or equal to 17 Years – United States 1991-1992, 44 MMWR 609 (1995).
6 American Lung Association, Trends in Asthma Morbidity and Mortality (July 2011), available at
http://www.lung.org/finding-cures/our-research/trend-reports/asthma-trend-report.pdf.
7 Center for Health Policy Research, Children in Foster Care: A Vulnerable Population in Health Care Reform, 1 Health Pol?y & Child Health 1, 3 (1994).
8 NAHIC, supra note 5, at 14.
9 Susan Wile Schwarz, Nat?l Ctr. for Children in Poverty, Adolescent Mental Health in the United States (2009); Arlene Rubin Stiffman et al., Adolescents? and Provider Perspectives on the
Need for and Use of Mental Health Services, 21 J. Adolescent Health 335 (1997); Shashi K. Bhatia et al., Childhood and Adolescent Depression, 75 Am. Fam. Physician 73 (2007).
10 Centers for Disease Control and Prevention, Sexual Risk Behavior: HIV, STD, & Teen Pregnancy Prevention (2012), available at http://www.cdc.gov/HealthyYouth/sexualbehaviors/.
11 Id.
12 Gladys Martinez et al., Teenagers in the United States: Sexual Activity, Contraceptive Use, and Childbearing, 2006-2010 National Survey of Family Growth, 23 Vital & Health Stat. 31 (2011).
13 Centers for Disease Control and Prevention, HIV Surveillance Report, 2008 (2010), available at http://www.cdc.gov/hiv/topics/surveillance/resources/reports>.
14 Guttmacher Inst., U.S. Teenage Pregnancies, Births and Abortions, 2008: National Trends by
Race and Ethnicity, 2010 (2012), available at http://www.guttmacher.org/pubs/USTPtrends08.pdf. 15 Id.
16 Guttmacher, supra note 14; Lawrence B. Finer & Mia R. Zolna, Unintended pregnancy in the United States: incidence and disparities, 2006, 84 Contraception 478 (2011).
17 Todd Callahan & William Cooper, Uninsurance and Health Care Access Among Young Adults in the United States, 116 Pediatrics 88 (2005); Margaret McManus et al., Health insurance
Status of Young Adults in the United States, 84 Pediatrics 709 (1989).
18 Sally Adams et al., Health Insurance Across Vulnerable Ages: Patterns and Disparities From Adolescence to the Early 30s, 119 Pediatrics 1033 (2007).
19 Id.
20 Kaiser Comm?n on Medicaid & Uninsured, Health Coverage of Children: The Role of Medicaid and CHIP (July 2012), available at http://www.kff.org/uninsured/upload/7698-06.pdf [hereinafter
Health Coverage of Children].
21 Id.
22 Id.
