CAHL UCSF ACA & Young Adult Issue Brief _Final_Mar22

CenterforAdolescentHealth&theLaw

NationalAdolescentandYoungAdultHealthInformationCenter

March2012

INTRODUCTION

AbigailEnglish,JD,CenterforAdolescentHealth&theLaw&M.JanePark,MPH,NAHIC,UCSanFrancisco

Access to Health Care for Young Adults: 

The Affordable Care Act of 2010 is Making a Difference



HEALTHINSURANCEFORYOUNGADULTS

EFORETHEACA

InDecember2011,theU.S.DepartmentofHealth&Human

Services(HHS)announcedthatasaresultofinitial

implementationoftheAffordableCareAct(ACA)2.5million

moreyoungadultsages19to25havehealthinsurancethan

wouldhavebeencoveredwithouttheACA.Thisrepresentsa

majorstep

forwardforanagegroupthathaslaggedbehind

othersinhavingcoverage:youngadultshavelongbeen

uninsuredandunderinsuredcomparedtoadolescentsand

olderadults.Thisagegroupalsoexperiencesawidevarietyof

healthconcerns,oftenmoreseverethanthoseaffecting

adolescents.Inadditiontoexpandingaccess

toprivate

insuranceforyoungadults,theACAwillexpandMedicaid

eligibilityforthisagegroupandimproveaccesstopreventive

services.Thisissuebriefdiscussestherecentgainsininsurance

coverageforyoungadultsandexplainsthebroadercontextof

theACAinwhichtheyhaveoccurred.



In2009,theyearbeforetheACAwasenacted,nearly15million

youngadultsages19to29wereuninsured,accordingtoU.S.

Censusdata.Thisrepresentedaboutonethirdoftheyoung

peopleinthatagegroup,andanincreaseof4million

uninsuredyoungadultsoverthepast

10years.Indeed,anew

studyfromHHSshowsthat,between2008and2010,privately‐

insuredyoungadultsages19to25weremorethantwiceas

likelytobecomeuninsured,comparedtoprivately‐insured

adultsages26to60.Therearemanyreasonsyoungadultslose

healthinsurance,including:

losingcoverageunderafamily

policyupongraduationfromhighschoolorcollege;losing

MedicaidorCHIPeligibilityuponreachingage19;being

employedinlowwagejobswithoutbenefits;orbeing

unemployed.

Fortheyoungadultswithouthealthinsurance,orlacking

adequatecoverage,theeffectsaresignificant.Forexample,a

2010CommonwealthFundstudyfoundthatoverall45%of

youngadultsreporteddelayingneededcarebecauseofcosts,

and58%ofuninsuredyoungadultshaddifficultypaying

medicalbills.

POLICYPROGRESSFORYOUNGADULTS

INTHEACA

theMedicaidexpansionsandtheprivateinsuranceprovisions

scheduledforlaterimplementationareinplace,theyalsowill

haveahugeimpactbyfurtherextendingcoverage,especiallyto

poorandlower‐incomeyoungadults–thosewhohavebeenat

greatestriskforbeinguninsured.

Beginningin2014,onceallof

theACA’sprovisionshavetaken

effect,morethan12millionofthenearly15millionuninsured

adultsages19to29couldobtainsubsidizedcoverage,

accordingtoananalysisbytheCommonwealthFund.Ofthese,

morethan7millionmaygaincoverageunderMedicaidand

nearly5millionmaygain

subsidizedprivatehealthinsurance

coveragethroughthehealthinsuranceexchangescreated

pursuanttotheACA.TheACAwillnotreachthenearly2

millionundocumentedyoungadultswhoareuninsured.

Youngadultsdonothavetowaituntil2014toreapsomeofthe

benefitsoftheACA.Asreportedin

December2011byHHS,2.5

millionhavealreadybenefittedbybeingabletoremainona

parent’sorfamily’shealthinsurancepolicyuptoage26,and

importantprovisionsrequiringcoverageofpreventiveservices

withoutcostsharingalsohavealreadytakeneffect.

TheACAoffersthepotentialforimprovingaccess

tohealth

careforyoungadultsinatleastfourimportantways.First,it

requireshealthinsuranceplansthatofferdependentcoverage

toallowdependentstoremainonaparent’sorfamily’spolicy

uptoage26.Second,itrequiresstrongerprotectionsfor

studentsandtheirdependentsinhealthplansoffered

by

collegesanduniversities.Third,itwillenablemillionsofyoung

adultstoreceivesubsidizedcoveragethroughhealthinsurance

exchangesoncetheActisfullyimplemented.Finally,itrequires

healthplanstoofferpreventiveserviceswithoutcostsharing.

PRIVATEINSURANCE

DependentCoverage

In2010,therewere29.7millionyoungadultsages19to25,

accordingtoU.S.Censusdata.Overa9‐monthperiod,from

September2010throughJune2011,theproportionofyoung

adultswithinsuranceincreasedfrom64.4%to72.7%,an

increaseof8.3%,or2.5millionnewlyinsuredyoungadults

in

thatagegroup.

Thereasonthatthese2.5millionadditionalyoungadultswere

abletogainhealthinsurancecoverageinlate2010andearly

2011isthatbeginninginSeptember2010healthplansoffering

dependentcoveragehavebeenrequiredtoallowyoungpeople

tostayonaparent’sorfamily’splanuntiltheir26

birthday.

Thisextendeddependentcoveragemustbeofferedregardless

oftheyoungperson’sage,financialindependenceordependent



TheACA,enactedonMarch23,2010,couldhaveadramatic

impactontheseproblemsbyexpandingaccesstobothprivate

healthinsuranceandMedicaid.Itisintheprivatehealthinsur‐

ancerealmthattheACAalreadyhashadanotableeffect.Once

CenterforAdolescentHealth&theLaw

NationalAdolescentandYoungAdultHealthInformationCenter

March2012

PRIVATEINSURANCE(CONT’D)

Page2Access to Health Care for Young Adults:

The Affordable Care Act of 2010 is Making a  Difference

BoththeACAitselfanditsimplementingregulationscontain

requirementsforstudenthealthplansatcollegesand

universitiesthatrepresentsignificantconsumerprotectionsfor

students.Forexample,mostcollegeanduniversitystudent

healthplanswillbelimitedintheirabilitytodenyenrollment

basedonmedicalcondition,ortoimposepre

‐existingcondition

exclusions,orannualorlifetimelimitsonbenefits.Theywill

alsoberequiredtooffercoveragetoallstudentsandtheir

dependents.Theseplanswillgenerallybetreatedasindividual

marketinsuranceplanssubjecttoACArequirementsforthe

individualmarket.

SubsidizedCoveragethroughExchanges

CollegeandUniversityHealthPlans

PreventiveServices

DependentCoverage(cont’d)

status,marriage,oreducationalenrollment.Thepremiums

chargedandthebenefitscoveredmustbethesameasfor

youngerchildrenunderthesamepolicy.TheACArequirement

appliestobothself‐insuredandfully‐insuredemployer‐based

plansaswellasplanssoldintheindividualmarket.Itincludes

bothnew

andgrandfatheredplans(i.e.,thoseinexistencewhen

theACAwasenacted),butyoungadultscanonlyenrollas

dependentsingrandfatheredplansiftheydon’thaveaccessto

anemployer‐basedplanontheirownorthroughaspouse.

PriortoenactmentoftheACA,37statesalreadyhadlaws

requiringthecontinuationofdependentcoverageforyoung

adults.Theupperagelimitsinthesestatelawsvaryfrom23to

31.Definitionsof“dependent”alsovary;andmanyofthelaws

requirefinancialdependenceorfull‐timestudentstatus,or

excludeyoungadultswhoaremarried.UnliketheACA,

none

ofthestatelawscoversself‐insuredplans.Theage26specified

intheACAestablishesaminimum,butyoungadultscanstill

enrollbeyondage26iftheirstate’slawsetsahigheragelimit;

theycannotbedeniedcoverageiftheirstate’slawsetsalower

age

limitorestablishesotherrestrictionsthattheydonotmeet.

Thus,thedependentcoveragemadeavailablebytheACA

reachesfarmoreyoungpeoplethanwerereachedbystatelaws

enactedpriortotheACA.NewresearchbyHHSshowsthatthe

ACA’sexpansionofdependentcoveragebenefitsyoungadults

allracesandethnicities.

assistancewillbeavailabletoindividualswithincomesupto

400%ofthefederalpovertylevel(FPL).Accordingtoan

analysisbytheCommonwealthFund,4.9millionyoungadults

ages19to29withincomesfrom133%to399%FPLwillqualify

forthesecreditsand

subsidiesin2014.

Forallprivatehealthinsurancepolicies–employer‐basedand

individualmarketpoliciesandthoseofferedthroughthe

exchanges–insurerswillnolongerbeabletoimposepre‐

existingconditionexclusionsandwillberequiredtoissue

policiesregardlessofanindividual’shealthormedical

condition.Asimilarrequirementwentintoeffectin2010for

children,buttherequirementforadultsthattakeseffectin2014

willhaveadramaticimpactonyoungadultswithavarietyof

illnessesandchronicconditions–suchasasthma,diabetes,and

cancer,amongmanyothers–whohavepreviouslybeenunable

toobtainhealthinsurancecoverageotherthanatexorbitantcost

orhavebeenentirelyunabletodoso.Thosewhohave

remaineduninsuredhavebornahugeburdenofout‐of‐pocket

medicalcostsorgonewithoutneededcare.

Theavailabilityoffinancialassistanceandtheestablishmentof

insuranceprotectionssuchastheeliminationofpre‐existing

conditionexclusionswilltogethercontributetobringingthe

youngadultpopulationclosertouniversalcoverageandto

reducingtheirfinancialburden.Therequirementfor

individualstopurchasehealthinsurancewillalsocontributeto

thesegoals.

Beginningin2014stateswillberequiredto

haveinplacehealth

insuranceexchangesthatwillallowindividualsandsmallbusi‐

nessestopurchasecoveragethatsatisfiesarangeofminimum

requirements.TheACArequiresstatestoestablishtheseex‐

changes,butspecifiesthat,ifnecessary,thefederalgovernment

willhelpthemdoso.

Throughtheseexchangesfinancialassistancewillbeavailable

tohelplower‐incomeindividualsaffordhealthinsuranceby

providingpremiumcreditsandcostsharingsubsidies.This

TheACArequiresprivatehealthplanstoofferarangeofpre‐

ventiveserviceswithoutimposingonpatientsanycostsharing

intheformofco‐payments,deductibles,andco‐insurance.The

requirementsapplytobothfully‐insuredandself‐insuredem‐

ployer‐basedplans,largegroup,smallgroup,andindividual

plans,withtheonlyexceptionforgrandfatheredplans.The

coveredservicesmustinclude:evidence‐basedscreeningand

counseling,routineimmunizations,preventiveservicesforchil‐

dren,andpreventiveservicesforwomen.



Theevidence‐basedscreeningandcounselingincludescreening

fordepression,diabetes,cholesterol,obesity,variouscancers,

HIVandsexuallytransmittedinfections(STIs),aswellascoun‐

selingfordrugandtobaccouse,healthyeating,andothercom‐

monhealthconcerns.Immunizationsincludethoserecom‐

mendedbytheAdvisoryCommitteeonImmunization

Practices

(ACIP)oftheCentersforDiseaseControlandPrevention

(CDC).BasedonrecommendationsfromanInstituteofMedi‐

cine(IOM)committee,federalregulationsrequireinsurersto

coverarangeofwomen’spreventiveserviceswithoutcost‐

sharing,including,amongothers,annualwell‐womanvisits,

testingforSTIsandHIV,andscreening

andcounselingfordo‐

mesticviolence.TherequirementsalsoincludeallFDA‐

approvedcontraceptionmethods.Eachofthesecategoriesis

importantandpotentiallyhighlybeneficialforyoungadults.

CenterforAdolescentHealth&theLaw

NationalAdolescentandYoungAdultHealthInformationCenter

March2012

Page3Access to Health Care for Young Adults:

The Affordable Care Act of 2010 is Making a  Difference

Youngadultsareapopulationwithsignificanthealthconcerns.

Inthepasttheyhavebeenuninsuredandunderinsuredat

significantlyhigherratesthanadolescentsandolderadults.The

ACAoffersthepromiseofhelpingthisagegroupreachnear

universalhealthinsurancecoveragethroughincreasedaccessto

bothprivateinsuranceand

Medicaid.TheActalsowillincrease

theiraccesstoimportantpreventivehealthservices.The

implementationofthedependentcoverageprovisionhas

alreadyprovidedamajorbenefittotheyoungadultpopulation

byenabling2.5millionyoungadultstogainhealthinsurance

whowouldnototherwisehavebeeninsured.

Importantquestionsremain,however,rangingfromspecific

issuesrelatedtovulnerablepopulationstobroadpolicy

questionsaffectingthefuturestatusoftheentireAct.For

example,willtheACAsucceedinactuallyenrollingvulnerable

groupssuchasformerfosteryouthorhomelessyouth;andwill

anywaybefoundtoprovidecoverageto

thenearly2million

youngadultswhoareundocumented?Therearealsomajor

unresolvedquestions–somecurrentlypendingintheU.S.

SupremeCourt‐‐abouttheconstitutionalityandlegalstatusof

severalprovisionsoftheACA,suchastherequirementthat

individualspurchasehealthinsurance.Neverthelessitis

hearteningtoseethattheACAhasalreadyresultedinamajor

advanceforyoungadults.

AsignificantproportionoftheACA’scontributiontoincreased

coverageforyoungadultswilloccurthroughitsexpansionof

Medicaideligibility.Effectivein2014,statesmustprovide

Medicaidcoveragetoalladultsunderage65withincomesup

to133%FPL.Suchcoveragehasbeenunavailableforchildless

adultswithoutdisabilities

invirtuallyallstates.In2012,133%

FPLforasinglechildlessadultis$14,856.

Beginningin2010,stateshadtheoptiontocoverchildless

adultswithoutdisabilitiesthroughastateplanamendment;

however,nosignificantincreaseinMedicaidcoveragefor

youngadultshasresultedsofar.By2014,when

theACAis

fullyimplemented,aCommonwealthFundanalysissuggests

that7.2millionyoungadultswhoarelegalU.S.residentsand

haveincomesunder133%FPLwillbecomeeligiblefor

Medicaid.

TheextenttowhichtheseMedicaidexpansionswillreach

especiallyvulnerablepopulationsisamixedpicture.For

example,about1

millionyoungadultswithincomesunder

133%FPLareundocumentedandwillnotbeeligiblefor

Medicaid.However,stateswillberequiredtocontinue

Medicaidcoverageforformerfosteryouthtoage26.

CONCLUSIONANDFUTUREQUESTIONS

ASPEOfficeofHealthPolicy,OfficeoftheAssistantSecretaryforPlanningand

Evaluation,U.S.DepartmentofHealthandHumanServices.2.5MillionYoung

AdultsGainHealthInsuranceDuetotheAffordableCareAct.Dec.14,2011.

http://aspe.hhs.gov/health/reports/2011/YoungAdultsACA/ib.shtml

.

ASPEOfficeofHealthPolicy,OfficeoftheAssistantSecretaryforPlanningand

Evaluation,U.S.DepartmentofHealthandHumanServices.NewReportShows

AffordableCareActHasExpandedInsuranceCoverageAmongYoungAdultsof

AllRacesandEthnicities.Mar.21,2012.http://aspe.hhs.gov/health/reports/2012/

YoungAdultsbyGroup/ib.shtml

CohenRA,MartinezME.Healthinsurancecoveragestatusforyoungadultsby

agegroup,year,andquarter,January2008–June2011.NationalCenterforHealth

Statistics.December2011.http://www.cdc.gov/nchs/health_policy/

coverage_and_access.htm.

CollinsSR,GarberT,RobertsonR.RealizingHealthReform’sPotential:Howthe

AffordableCareActIsHelpingYoungAdultsStayCovered,TheCommonwealth

Fund,May2011.http://www.commonwealthfund.org/Publications/Issue‐

Briefs/2011/May/Helping‐Young‐Adults.aspx.

DeNavas‐WaltC,ProctorBD,SmithJC.CensusBureau,CurrentPopulation

Reports,P60‐239,Income,Poverty,andHealthInsuranceCoverageintheUnited

States:2010.GovernmentPrintingOffice,Washington,DC,2011.

GallupPoll.Fewer18‐to26‐Year‐OldsinU.S.Uninsuredin2011.May4,2011.

http://www.gallup.com/poll/147422/Fewer‐Year‐Olds

‐Uninsured‐2011.aspx#1.

HeberleinMetal.PerformingUnderPressure:AnnualFindingsofa50‐State

SurveyofEligibility,Enrollment,Renewal,andCost‐SharingPoliciesinMedicaid

andCHIP,2011‐2012.KaiserCommissiononMedicaidandtheUninsured.

January2012.www.kff.org/medicaid/8272.cfm

.

IrwinCE,Jr.Youngadultsareworseoffthanadolescents.JAdolescHealth2010;

May;46(5):405‐6.

KaiserFamilyFoundation.PreventiveServicesCoveredbyPrivateHealthPlans

UndertheACA.KaiserFamilyFoundation,September2011.www.kff.org/

healthreform/upload/8219.pdf.

MartinezME,CohenRA.HealthInsurancecoverage:Earlyreleaseofestimates

fromtheNationalHealthInterviewSurvey,January‐June2011.NationalCenter

forHealthStatistics.December2011.http://www.cdc.gov/nchs/data/nhis/

earlyrelease/insur201112.pdf.

MulyeTP,ParkMJ,NelsonCD,AdamsSH,IrwinCE,Jr,BrindisCD.Trendsin

adolescentandyoungadulthealthintheUnitedStates.JAdolescHealth

2009;45:8–24.

NationalConferenceofStateLegislatures.CoveringYoungAdultsThroughTheir

Parents’orGuardians’HealthPolicy.http://www.ncsl.org/issues‐research/health/

dependent‐health‐coverage‐state‐implementation.aspx.

SchwartzK,SommersBD.YoungAdultsareParticularlyLikelytoGainStable

HealthInsurancecoverageasaResultoftheAffordableCareAct.Mar.21,2012.

http://aspe.hhs.gov/health/reports/2012/UninsuredYoungAdults/rb.pdf

SommersBD,KronickR.TheAffordableCareActandInsuranceCoveragefor

YoungAdults.JAMA2012;307:913‐4.

TrustforAmerica’sHealth.Preventionand

theAffordableCareAct:Prevention

BenefitstoYoungAdultsinAmerica.www.healthyamericans.org/assets/files/

Young%20Adults%20and%20ACA.pdf.

MEDICAID REFERENCESANDRESOURCES

CenterforAdolescentHealth&theLaw

NationalAdolescentandYoungAdultHealthInformationCenter

March2012

Page4Access to Health Care for Young Adults:

The Affordable Care Act of 2010 is Making a  Difference

CenterforAdolescentHealth&theLaw

POBox3795

ChapelHill,NC27515‐3795

ph.919.968.8850

e‐mail:[email protected]

http://www.cahl.org

TheCenterforAdolescentHealth&theLawisauniqueorganization

thatworksexclusivelytopromotethehealthofadolescentsandyoung

adultsandtheiraccesstocomprehensivehealthcare.Establishedin

1999,theCenterisanon‐profit,501(c)(3)organization.Working

nationally,theCenterclarifiesthecomplexlegaland

policyissuesthat

affectaccesstohealthcareforthemostvulnerableyouthintheUnited

States.TheCenterprovidesinformationandanalysis,publications,

consultation,andtrainingtohealthprofessionals,policymakers,

researchers,andadvocateswhoareworkingtoprotectthehealthof

adolescentsandyoungadults.

NationalAdolescentandYoungAdultHealthInformationCenter

UniversityofCalifornia,SanFrancisco

LHTSSuite245,Box0503

SanFrancisco,CA94143‐0503

ph.415.502.4856

f.415.502.4858

email:[email protected]

TheNationalAdolescentandYoungAdultHealthInformationCenter

(NAHIC)wasfirstestablishedastheNationalAdolescentHealth

InformationCenterin1993withfundingfromtheMaternalandChild

HealthBureau.TheoverallgoalofNAHICistoimprovethehealthof

adolescentsbyservingasanationalresourceforadolescent

andyoung

adulthealthinformationandresearch,andtoassuretheintegration,

synthesis,coordinationanddisseminationofadolescentandyoung

adulthealth‐relatedinformation.Throughoutitsactivities,NAHIC

emphasizestheneedsofspecialpopulationswhoaremoreadversely

affectedbythecurrentchangesinthesocialenvironmentofyoung

people

andtheirfamilies.

EnglishA,ParkMJ.AccesstoHealthCareforYoungAdults:The

AffordableCareActisMakinga Difference.ChapelHill,NC:Centerfor

AdolescentHealth&theLaw;andSanFrancisco,CA:National

AdolescentandYoungAdultHealthInformationCenter,2012.

SuggestedCitation:

Acknowledgements:

ThisissuebriefistheresultofacollaborationbetweentheCenterfor

AdolescentHealth&theLaw(CAHL)andtheNationalAdolescentand

YoungAdultHealthInformationCenter(NAHIC)attheUniversityof

California,SanFrancisco.Theauthorsgratefullyacknowledgethecon‐

tributionsoftheircolleaguesatNAHIC,especiallyClaire

Brindisand

CharlesE.Irwin,Jr.Theauthorsalsogivespecialthankstothe

CommonwealthFundforitsextensiveresourcesonyoungadultsand

healthcarereform.

Support:

Supportforthepreparationofthisdocumentwasprovidedinpartby

fundingfromtheMaternalandChildHealthBureau,HealthResources

andServicesAdministration,U.S.DepartmentofHealthandHuman

Services(U45MC00002&U45MC00023).AdditionalSupportwas

providedbythegenerosityofindividualdonorstotheCenterfor

AdolescentHealth

&theLaw.