Young Adults Are Worse Off Than Adolescents

Abstract

See Related Article p. 407The past decade has seen an increasing awareness of the health needs of young people as they transition from adolescence to young adulthood [1Park M.J. Mulye T.P. Adams S.H. et al.The health status of young adults in the US.J Adolesc Health. 2006; 39: 305-317Abstract Full Text Full Text PDF PubMed Scopus (297) Google Scholar, 2Furstenberg F.F. Growing up healthy: Are adolescents the right target group?.J Adolesc Health. 2006; 39: 303-304Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 3Paul T. Park M.J. Adams S.H. et al.Adolescent/young adult health in the US: Trends and implications.J Adolesc Health. 2009; 45: 8-24Abstract Full Text Full Text PDF PubMed Scopus (275) Google Scholar, 4Setterstein Jr., R.A. Frustenberg Jr., F.F. Rumbaut R.G. On the Frontier of Adulthood. University of Chicago Press, Chicago, IL2005Crossref Google Scholar]. When compared with adolescents, young adults have higher rates of mortality, health damaging behaviors, and chronic conditions including mental health disorders and obesity [[3]Paul T. Park M.J. Adams S.H. et al.Adolescent/young adult health in the US: Trends and implications.J Adolesc Health. 2009; 45: 8-24Abstract Full Text Full Text PDF PubMed Scopus (275) Google Scholar]. Given these prevalence data, one would expect higher rates of ambulatory care use during young adulthood than during adolescence. Instead, a different picture emerges from the analysis done by Callahan and Cooper and reported in this issue of the Journal of Adolescent Health[[5]Callahan S.T. Cooper W.O. Changes in ambulatory health care use during the transition to young adulthood.Adolesc Health. 2010; 46: 407-413Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar].Using data (1997–2004) from the National Ambulatory Care and National Hospital Ambulatory Care Surveys (NAMCS/NHAMCS), the authors document the changing patterns of health care utilization when adolescents (13–18 years old) enter young adulthood (19–24 years old). Even though the two groups represent similar numbers of annual visits, there are major differences in the settings in which care is received, the reasons for visits, the physician specialties providing care, and the sources of payment for the services received. When compared with adolescents, young adults receive a greater proportion of their ambulatory care in emergency departments (ED), a larger portion of their care is not covered by insurance, and gender differences become more apparent in all areas of health care utilization. Obstetricians/Gynecologists provide more of the care to young adult females than any other specialist, and preventive care is the major reason for this non-emergency care. The increase in preventive care for young adult females when compared with adolescent females is related to the increase in care for reproductive health. Young adult males present a very different picture — General or Adult Medicine Physicians deliver most of their care, with preventive care being the least likely reason for a visit and acute problems dominating the reasons for seeking care [[5]Callahan S.T. Cooper W.O. Changes in ambulatory health care use during the transition to young adulthood.Adolesc Health. 2010; 46: 407-413Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar].Callahan and Cooper's article lends further support to a series of studies documenting the plight of young adults as they attempt to utilize the existing health care system [6Adams S.H. Newacheck P.W. Park M.J. et al.Health insurance across the vulnerable ages: Patterns and disparities from adolescence to the early 30s.Pediatrics. 2007; 119: e1033-e1039Crossref PubMed Scopus (61) Google Scholar, 7Fortuna R.J. Robbins B.W. Halterman J.S. Ambulatory care in the United States.Ann Intern Med. 2009; 151: 379-385Crossref PubMed Scopus (91) Google Scholar, 8Nicholson J.L. Collins S.R. Mahato B. et al.Rite of passage? Why young adults become uninsured and how new policies can help [The Commonwealth Fund issue brief]. The Commonwealth Fund, New York, NY2009Google Scholar]. From a health policy perspective, five critical factors emerge with clarity: insurance matters, primary care specialists change, males have greater barriers to accessing primary care than females, clinical guidelines need to be developed to improve the quality and content of care that young adults receive, and young adulthood remains a missed opportunity for preventive interventions.First and foremost, many young adults do not have the necessary insurance coverage for them to take the first step for access to care. In the United States, young adults are twice as likely to be uninsured than any other age segment of the population, secondary to the loss of private or public coverage that they held as children, fewer opportunities for traditional employment-based coverage, and the inability to purchase health insurance independently. When adolescents “age out” of publically funded programs, most — with the exception of pregnant females — do not qualify for public programs [6Adams S.H. Newacheck P.W. Park M.J. et al.Health insurance across the vulnerable ages: Patterns and disparities from adolescence to the early 30s.Pediatrics. 2007; 119: e1033-e1039Crossref PubMed Scopus (61) Google Scholar, 8Nicholson J.L. Collins S.R. Mahato B. et al.Rite of passage? Why young adults become uninsured and how new policies can help [The Commonwealth Fund issue brief]. The Commonwealth Fund, New York, NY2009Google Scholar]. Most young adults will have some time during which they do not have insurance, leading them not to seek care when they need care and high rates of Emergency Department (ED) use. In the current analysis, one in three visits to the ED was not covered by any form of insurance, with young adult males being more adversely affected than females [[5]Callahan S.T. Cooper W.O. Changes in ambulatory health care use during the transition to young adulthood.Adolesc Health. 2010; 46: 407-413Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar]. The past few years have seen several efforts at the state and federal level to expand the provision of insurance coverage for young adults. Currently, 26 states have passed legislation that increases the age of dependency for young adults for purposes of private insurance coverage [[8]Nicholson J.L. Collins S.R. Mahato B. et al.Rite of passage? Why young adults become uninsured and how new policies can help [The Commonwealth Fund issue brief]. The Commonwealth Fund, New York, NY2009Google Scholar]. In addition, the federal government has given states financial incentives to continue foster care maintenance payments on behalf of children until age 21 [[9]Congress of the United States. Fostering Connections to Success and Increasing Adoptions Act 2008. Available at: www.govtrack.us/congress/billtext.xpd?bill=h110-689. Accessed February 19, 2010.Google Scholar]. Some states also require that students enrolled in college must have insurance coverage to enroll in school.Second, physicians with a specialty in Obstetrics/Gynecology play a critical role in the delivery of preventive care to young adult women. Increasingly, young women as they enter young adulthood go to Obstetrician/Gynecologists to meet their primary care needs [[10]Hoover K.W. Tao G. Berman S.M. Utilization of health services in physician offices and outpatient clinics by adolescents and young women in the United States: Implications for improving access to reproductive health services.J Adolesc Health. 2010; 46: 324-330Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar]. The American College of Obstetrics/Gynecology (ACOG) has responded to this new demand on their specialists by developing clinical guidelines for the care of young women [[11]ACOG Committee on Gynecologic PracticeACOG Committee Opinion No. 357: Primary and preventive care: Periodic assessments.Obstet Gynecol. 2006; 108: 1615-1622Crossref PubMed Scopus (33) Google Scholar]. Unlike females, males do not have a designated specialty-provider for their care. Young men between the ages of 20–29 years have the lowest utilization rates of any age group, including adolescents [5Callahan S.T. Cooper W.O. Changes in ambulatory health care use during the transition to young adulthood.Adolesc Health. 2010; 46: 407-413Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar, 7Fortuna R.J. Robbins B.W. Halterman J.S. Ambulatory care in the United States.Ann Intern Med. 2009; 151: 379-385Crossref PubMed Scopus (91) Google Scholar]. Given that males are more likely than females to not have insurance coverage and most do not want to incur a debt burden, these young men are making a rational decision by not seeking preventive care at this point in their life [[8]Nicholson J.L. Collins S.R. Mahato B. et al.Rite of passage? Why young adults become uninsured and how new policies can help [The Commonwealth Fund issue brief]. The Commonwealth Fund, New York, NY2009Google Scholar]. Of concern is the fact that young black and Hispanic men access care at even lower rates than young white men. With the marked disparities in health outcomes between whites and black and Hispanic men, the lack of ability to access primary care may have an additional effect on morbidity and mortality during the third decade of life.Third, with the exception of the ACOG Guidelines for young women, clinical guidelines are not available for this age group. The recent publication of Bright Futures provides clinical guidelines for adolescents and young adults through their 21st birthday [[11]ACOG Committee on Gynecologic PracticeACOG Committee Opinion No. 357: Primary and preventive care: Periodic assessments.Obstet Gynecol. 2006; 108: 1615-1622Crossref PubMed Scopus (33) Google Scholar]. Without age-specific guidelines for screening and anticipatory guidance for young adulthood aged >21 years, clinicians may not know what should be included in an annual preventive visit. Clearly, clinical guidelines neither guarantee what is covered by insurance nor ensure quality of care, as has been demonstrated by the adolescent-specific guidelines, but they do provide a roadmap for what should be done in clinical practice [[12]Hagan J.F. Shaw J.S. Duncan P.M. Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents.3rd ed. American Academy of Pediatrics, Elk Grove Village, IL2008Google Scholar].Fourth, young adulthood is a “missed opportunity” similar to adolescence [13Irwin CE Jr., Adams SA, Park JM, et al. Preventive care for adolescents: Few get visits, and fewer get services. Pediatrics 123:e565–e572.Google Scholar, 14Lawrence R.S. Appleton Gootman J. Sim L.J. National Research Council and Institute of Medicine, Committee on Adolescent Health Care Services and Models of Care for Treatment, Prevention and Healthy Development, Board on Children, Youth and Families, Division of Behavioral and Social Sciences and Education.in: Adolescent Health Care Services: Missing Opportunities. National Academies Press, Washington, DC2009Google Scholar]. Young adulthood represents a critical point in the life cycle, during which young adults are beginning to assume responsibility for their own care and develop a relationship with a primary care provider. If they do not have the opportunity to establish this relationship at this point in their lives, whether they will engage at another time remains an open question.The high rates of mortality for young adults, the continued onset of both negative and positive health behaviors that are associated with health outcomes, the significant gender and racial disparities, and the lack of health insurance for this age group, make it incumbent upon us to encourage policy makers to seek opportunities for young adults to be brought into the health care system. See Related Article p. 407 See Related Article p. 407 See Related Article p. 407 The past decade has seen an increasing awareness of the health needs of young people as they transition from adolescence to young adulthood [1Park M.J. Mulye T.P. Adams S.H. et al.The health status of young adults in the US.J Adolesc Health. 2006; 39: 305-317Abstract Full Text Full Text PDF PubMed Scopus (297) Google Scholar, 2Furstenberg F.F. Growing up healthy: Are adolescents the right target group?.J Adolesc Health. 2006; 39: 303-304Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 3Paul T. Park M.J. Adams S.H. et al.Adolescent/young adult health in the US: Trends and implications.J Adolesc Health. 2009; 45: 8-24Abstract Full Text Full Text PDF PubMed Scopus (275) Google Scholar, 4Setterstein Jr., R.A. Frustenberg Jr., F.F. Rumbaut R.G. On the Frontier of Adulthood. University of Chicago Press, Chicago, IL2005Crossref Google Scholar]. When compared with adolescents, young adults have higher rates of mortality, health damaging behaviors, and chronic conditions including mental health disorders and obesity [[3]Paul T. Park M.J. Adams S.H. et al.Adolescent/young adult health in the US: Trends and implications.J Adolesc Health. 2009; 45: 8-24Abstract Full Text Full Text PDF PubMed Scopus (275) Google Scholar]. Given these prevalence data, one would expect higher rates of ambulatory care use during young adulthood than during adolescence. Instead, a different picture emerges from the analysis done by Callahan and Cooper and reported in this issue of the Journal of Adolescent Health[[5]Callahan S.T. Cooper W.O. Changes in ambulatory health care use during the transition to young adulthood.Adolesc Health. 2010; 46: 407-413Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar]. Using data (1997–2004) from the National Ambulatory Care and National Hospital Ambulatory Care Surveys (NAMCS/NHAMCS), the authors document the changing patterns of health care utilization when adolescents (13–18 years old) enter young adulthood (19–24 years old). Even though the two groups represent similar numbers of annual visits, there are major differences in the settings in which care is received, the reasons for visits, the physician specialties providing care, and the sources of payment for the services received. When compared with adolescents, young adults receive a greater proportion of their ambulatory care in emergency departments (ED), a larger portion of their care is not covered by insurance, and gender differences become more apparent in all areas of health care utilization. Obstetricians/Gynecologists provide more of the care to young adult females than any other specialist, and preventive care is the major reason for this non-emergency care. The increase in preventive care for young adult females when compared with adolescent females is related to the increase in care for reproductive health. Young adult males present a very different picture — General or Adult Medicine Physicians deliver most of their care, with preventive care being the least likely reason for a visit and acute problems dominating the reasons for seeking care [[5]Callahan S.T. Cooper W.O. Changes in ambulatory health care use during the transition to young adulthood.Adolesc Health. 2010; 46: 407-413Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar]. Callahan and Cooper's article lends further support to a series of studies documenting the plight of young adults as they attempt to utilize the existing health care system [6Adams S.H. Newacheck P.W. Park M.J. et al.Health insurance across the vulnerable ages: Patterns and disparities from adolescence to the early 30s.Pediatrics. 2007; 119: e1033-e1039Crossref PubMed Scopus (61) Google Scholar, 7Fortuna R.J. Robbins B.W. Halterman J.S. Ambulatory care in the United States.Ann Intern Med. 2009; 151: 379-385Crossref PubMed Scopus (91) Google Scholar, 8Nicholson J.L. Collins S.R. Mahato B. et al.Rite of passage? Why young adults become uninsured and how new policies can help [The Commonwealth Fund issue brief]. The Commonwealth Fund, New York, NY2009Google Scholar]. From a health policy perspective, five critical factors emerge with clarity: insurance matters, primary care specialists change, males have greater barriers to accessing primary care than females, clinical guidelines need to be developed to improve the quality and content of care that young adults receive, and young adulthood remains a missed opportunity for preventive interventions. First and foremost, many young adults do not have the necessary insurance coverage for them to take the first step for access to care. In the United States, young adults are twice as likely to be uninsured than any other age segment of the population, secondary to the loss of private or public coverage that they held as children, fewer opportunities for traditional employment-based coverage, and the inability to purchase health insurance independently. When adolescents “age out” of publically funded programs, most — with the exception of pregnant females — do not qualify for public programs [6Adams S.H. Newacheck P.W. Park M.J. et al.Health insurance across the vulnerable ages: Patterns and disparities from adolescence to the early 30s.Pediatrics. 2007; 119: e1033-e1039Crossref PubMed Scopus (61) Google Scholar, 8Nicholson J.L. Collins S.R. Mahato B. et al.Rite of passage? Why young adults become uninsured and how new policies can help [The Commonwealth Fund issue brief]. The Commonwealth Fund, New York, NY2009Google Scholar]. Most young adults will have some time during which they do not have insurance, leading them not to seek care when they need care and high rates of Emergency Department (ED) use. In the current analysis, one in three visits to the ED was not covered by any form of insurance, with young adult males being more adversely affected than females [[5]Callahan S.T. Cooper W.O. Changes in ambulatory health care use during the transition to young adulthood.Adolesc Health. 2010; 46: 407-413Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar]. The past few years have seen several efforts at the state and federal level to expand the provision of insurance coverage for young adults. Currently, 26 states have passed legislation that increases the age of dependency for young adults for purposes of private insurance coverage [[8]Nicholson J.L. Collins S.R. Mahato B. et al.Rite of passage? Why young adults become uninsured and how new policies can help [The Commonwealth Fund issue brief]. The Commonwealth Fund, New York, NY2009Google Scholar]. In addition, the federal government has given states financial incentives to continue foster care maintenance payments on behalf of children until age 21 [[9]Congress of the United States. Fostering Connections to Success and Increasing Adoptions Act 2008. Available at: www.govtrack.us/congress/billtext.xpd?bill=h110-689. Accessed February 19, 2010.Google Scholar]. Some states also require that students enrolled in college must have insurance coverage to enroll in school. Second, physicians with a specialty in Obstetrics/Gynecology play a critical role in the delivery of preventive care to young adult women. Increasingly, young women as they enter young adulthood go to Obstetrician/Gynecologists to meet their primary care needs [[10]Hoover K.W. Tao G. Berman S.M. Utilization of health services in physician offices and outpatient clinics by adolescents and young women in the United States: Implications for improving access to reproductive health services.J Adolesc Health. 2010; 46: 324-330Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar]. The American College of Obstetrics/Gynecology (ACOG) has responded to this new demand on their specialists by developing clinical guidelines for the care of young women [[11]ACOG Committee on Gynecologic PracticeACOG Committee Opinion No. 357: Primary and preventive care: Periodic assessments.Obstet Gynecol. 2006; 108: 1615-1622Crossref PubMed Scopus (33) Google Scholar]. Unlike females, males do not have a designated specialty-provider for their care. Young men between the ages of 20–29 years have the lowest utilization rates of any age group, including adolescents [5Callahan S.T. Cooper W.O. Changes in ambulatory health care use during the transition to young adulthood.Adolesc Health. 2010; 46: 407-413Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar, 7Fortuna R.J. Robbins B.W. Halterman J.S. Ambulatory care in the United States.Ann Intern Med. 2009; 151: 379-385Crossref PubMed Scopus (91) Google Scholar]. Given that males are more likely than females to not have insurance coverage and most do not want to incur a debt burden, these young men are making a rational decision by not seeking preventive care at this point in their life [[8]Nicholson J.L. Collins S.R. Mahato B. et al.Rite of passage? Why young adults become uninsured and how new policies can help [The Commonwealth Fund issue brief]. The Commonwealth Fund, New York, NY2009Google Scholar]. Of concern is the fact that young black and Hispanic men access care at even lower rates than young white men. With the marked disparities in health outcomes between whites and black and Hispanic men, the lack of ability to access primary care may have an additional effect on morbidity and mortality during the third decade of life. Third, with the exception of the ACOG Guidelines for young women, clinical guidelines are not available for this age group. The recent publication of Bright Futures provides clinical guidelines for adolescents and young adults through their 21st birthday [[11]ACOG Committee on Gynecologic PracticeACOG Committee Opinion No. 357: Primary and preventive care: Periodic assessments.Obstet Gynecol. 2006; 108: 1615-1622Crossref PubMed Scopus (33) Google Scholar]. Without age-specific guidelines for screening and anticipatory guidance for young adulthood aged >21 years, clinicians may not know what should be included in an annual preventive visit. Clearly, clinical guidelines neither guarantee what is covered by insurance nor ensure quality of care, as has been demonstrated by the adolescent-specific guidelines, but they do provide a roadmap for what should be done in clinical practice [[12]Hagan J.F. Shaw J.S. Duncan P.M. Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents.3rd ed. American Academy of Pediatrics, Elk Grove Village, IL2008Google Scholar]. Fourth, young adulthood is a “missed opportunity” similar to adolescence [13Irwin CE Jr., Adams SA, Park JM, et al. Preventive care for adolescents: Few get visits, and fewer get services. Pediatrics 123:e565–e572.Google Scholar, 14Lawrence R.S. Appleton Gootman J. Sim L.J. National Research Council and Institute of Medicine, Committee on Adolescent Health Care Services and Models of Care for Treatment, Prevention and Healthy Development, Board on Children, Youth and Families, Division of Behavioral and Social Sciences and Education.in: Adolescent Health Care Services: Missing Opportunities. National Academies Press, Washington, DC2009Google Scholar]. Young adulthood represents a critical point in the life cycle, during which young adults are beginning to assume responsibility for their own care and develop a relationship with a primary care provider. If they do not have the opportunity to establish this relationship at this point in their lives, whether they will engage at another time remains an open question. The high rates of mortality for young adults, the continued onset of both negative and positive health behaviors that are associated with health outcomes, the significant gender and racial disparities, and the lack of health insurance for this age group, make it incumbent upon us to encourage policy makers to seek opportunities for young adults to be brought into the health care system. Changes in Ambulatory Health Care Use During the Transition to Young AdulthoodJournal of Adolescent HealthVol. 46Issue 5PreviewTo identify changes in ambulatory health care use during the transition from adolescence to young adulthood. Full-Text PDF