3/12/2014 MonitoringtheImpactoftheACA: Howwillyoungadultsandwomenfareina changinghealthcareenvironment? Claire D. Brindis, Dr. P.H., Director Philip R. Lee Institute for Health Policy Studies Professor of Pediatrics and Health Policy University of California, San Francisco UCS Mini‐Medical School March 13, 2014 4 1 3/12/2014 HealthCareforYoungAdults: SomeProgress,ManyChallenges Critical Health Issues of Adolescence and Young Adults • Increasing independence in habits ‐‐ diet, physical activity, and sleep. • Critical period to prevent chronic conditions of adulthood, in areas such as • Transition to adult health care systems is often abrupt. • Lower insurance rates • Diseases related to tobacco use, • Obesity (related to diabetes, heart disease, cancer), • Dental caries, • Hearing loss. • 15.7% of residents in the US lack insurance • 27% of 18‐34 year olds in the US lack insurance • Very little professional focus on standards of care for this age population; however, clinical guidelines for prevention are available. *Adapted from the Healthy People 2020 Core Indicators for Adolescent and Young Adult Health al., 2012; NAHIC, 2013; IOM 2013; Martinez et al., 2013 5 MedicaidExpansion: DependsontheState Currently Eligible: • Low‐income children, pregnant women, disabled individuals, and seniors Newly Eligible, if Expanded: • Everyone with income at or below 133% FPL (about $15,280 annually) • About 7.8 million young adults could become eligible for Medicaid under expansion, if they live in the “right” state 10 EssentialHealthBenefits Ambulatory patient services Emergency services Hospitalization Maternity/newborn care Mental health and substance use disorder services Prescription drugs Rehabilitative and habilitative services Laboratory services Preventive and wellness services/chronic disease management Pediatric services 2 3/12/2014 ACAEvaluationApproaches Potential Sources of Quantitative Data National Health Interview Survey Medical Expenditures Panel Survey (MEPS) Behavioral Risk Surveillance System National Ambulatory Medical Care Survey California Health Interview Survey (CHIS) Kaiser Women’s Health Survey (2001, 2005, 2009, 2013, 2017). MentalHealthNeeds • 1 in 5 young adults between ages 18‐25 experienced mental disorders last year • Highest rates of psychological distress & suicidal thoughts & attempts of any nearby age group • 18‐25 year olds have highest rates of binge drinking & tobacco use of surrounding age groups Picture Source: http://www.theguardian.com/society/2012/feb/29/mental‐ health‐cash‐boost MentalHealthBenefits • Mental Health Parity + Essential Health Benefits (includes substance abuse services) • Requires insurers to provide mental health benefits comparable to other medical care coverage • Employee Benefit Research Institute (EBRI) Study on the Impact of Dependent Coverage Expansion on one large national employer : • Increase in use of services • 42% of all inpatient claims were used for mental health & substance abuse services after 1 year of coverage 3 3/12/2014 QualitativeMethods Thereisanawarenessgap 71% of uninsured 18‐29 year olds don’t know of new options for insurance 83% of the Medicaid expansion population don’t know of new options for insurance Informing Enroll America’s Campaign: Communicating to 18‐29 Year Olds. Conducted by Lake Research Partners. February 2013. UseLanguageCautiously Be Careful Here’s Why “Exchange” People think “Exchange” is a “Marketplace” place to trade or swap merchandise and don’t immediately associate it with health care. Messages that only mention “your family” “Financial Assistance Available” Use This Instead Single and childless people “Individuals” have trouble identifying with messages exclusively about “family” The concept needs more exploration. Many consumers think “assistance” is for someone else, not them. YourHealthCareFinder “You may be eligible for a $0 premium plan or a new type of tax credit that lowers your monthly payment”  Find doctors and Community Health Centers in your area  Search by location with GPS or zip code, name or category  Explains the health care law  Defines common health insurance terms ResearchfromCentersforMedicareandMedicaidServices 4 3/12/2014 Women’sHealthEvaluation The ACA Makes Many Insurance Reforms Affecting Women Before ACA After ACA • No uniform national policy regarding dependent coverage age limits • Dependent coverage extended to age 26, Uninsured rate for women 19‐25 fell from 30% in 2009 to 25% in 2012 • Pregnancy and history of domestic violence could be considered pre‐ existing conditions • No pre‐existing condition exclusions • Individual insurance plans could charge higher premiums to women. Many did. • Plans are no longer permitted to use gender to determine premiums: gender‐rating banned • Individual insurance plans typically excluded maternity care, considered pregnancy a “pre‐ex”, or required costly riders for coverage. Only employer plans required to cover maternity care. Adult Preventive Services to be Covered by Private Plans Without Cost Sharing Cancer Chronic Conditions Vaccines Healthy Behaviors Pregnancy Reproductive and Sexual Health Breast Cancer Cardiovascular health ⁻ Hypertension screening ⁻ Lipid disorders screenings ⁻ Aspirin Td booster, Tdap Alcohol misuse STI and HIV counseling (adults at Type 2 Diabetes  Hepatitis A, B – Mammography for women 40+* – Genetic (BRCA) screening and counseling – Preventive medication Cervical Cancer ‒ Pap testing (women 21+ ) • Individually purchased plans and employer‐based plans include maternity care • Plans were not required to cover • ALL new plans must cover preventive services without cost recommended preventive services sharing. without cost‐sharing. Source: Kaiser Family Foundation, Health Reform: Implications for Women’s Access to Coverage and Care, 2013. ‒ High‐risk HPV DNA testing ♀ Colorectal Cancer ⁻ screening (adults w/ elevated blood pressure) Depression screening (adults, when follow up supports available) Osteoporosis One of following: screening (all women fecal occult blood 65+, women 60+ at testing, colonoscopy, high risk) sigmoidoscopy Obesity Screening (all adults) Counseling and behavioral interventions (obese adults) MMR Meningococcal Pneumococcal Zoster Influenza, Varicella HPV (women and men 19‐ 26) screening and counseling (all adults) Tobacco and cessation interventions Alcohol misuse screening/counseling Diet counseling (adults w/high cholesterol, CVD risk factors, diet‐related chronic disease) Tobacco counseling and cessation interventions (all adults) Interpersonal and domestic violence screening and counseling (women 18‐64)♀ Well‐woman visits (women 18‐64) ♀ Rh incompatibility screening  Gestational diabetes screenings♀ ⁻ ⁻ 24‐28 weeks gestation First prenatal visit (women at high risk for diabetes) Screenings ⁻ ⁻ ⁻ ⁻ ⁻ Hepatitis B Chlamydia (<24, hi risk) Gonorrhea Syphilis Bacteriurea Folic acid supplements (women w/repro capacity) Iron deficiency anemia screening Breastfeeding supports, ⁻ counseling , consultations and equipment rental♀ high risk; all sexually‐ active women♀) Screenings: ⁻ Chlamydia (sexually active women <24y/o, older women at high risk) ⁻ Gonorrhea (sexually active women at high risk) ⁻ Syphilis (adults at high risk) ⁻ HIV (adults at high risk; all sexually active women♀) Contraception (women w/repro capacity) ♀ ⁻ All FDA approved methods as prescribed, ⁻ Sterilization procedures ⁻ Patient education and counseling SOURCE: U.S. DHHS, “Recommended Preventive Services.” Available at http://www.healthcare.gov/center/regulations/prevention/recommendations.html. More information about each of the services in this table, including details on periodicity, risk factors, and specific test and procedures are available at the following websites: USPSTF: http://www.uspreventiveservicestaskforce.org/recommendations.htm ACIP: http://www.cdc.gov/vaccines/pubs/ACIP‐list.htm#comp HRSA Women’s Preventive Services: http://www.hrsa.gov/womensguidelines/ 5 3/12/2014 21 6