Improving Receipt and Preventive Care Delivery for Adolescents and Young Adults: Initial Lessons from Top-Performing States.

Purpose Provisions of the Patient Protection and Affordable Care Act (ACA) of 2010 hold promise for improving access to and receipt of preventive services for adolescents and young adults (AYAs). The Title V Block Grant transformation also includes a focus on improving adolescent preventive care. This brief report describes and discusses an inquiry of promising strategies for improving access and preventive care delivery identified in selected high-performing states. Methods Two data sources were used to identify top-performing states in insurance enrollment and preventive care delivery: National Survey of Children's Health for adolescents (ages 12-17 years) and Behavioral Risk Factors Surveillance System for young adults (ages 18-25 years). Interviews were conducted with key stakeholders to identify promising strategies related to increasing AYAs' insurance enrollment and receipt of preventive services. Results Seven top-performing states were selected: California, Colorado, Illinois, Iowa, Oregon, Vermont, and Texas; 27 stakeholders completed interviews. Four strategies were identified regarding insurance enrollment: use of partnerships; special populations outreach; leveraging laws and resources; and youth engagement. Four strategies were identified regarding quality preventive care: expand provider capacity to serve AYAs; adopt medical home policies; establish quality improvement projects; and enhance consumer awareness of well-visit. States focused more on adolescents than young adults and on increasing health insurance enrollment than the provision of preventive services. Conclusions This commentary identifies strategies and recommends areas for future action, as Title V programs and their partners focus on improving healthcare for AYAs as ACA implementation and the Title V transformation continues.

Young Adult Preventive Healthcare: Changes in Receipt of Care Pre- to Post-Affordable Care Act.

PURPOSE: Young adults have unique health and health care needs. Although morbidity and mortality stem largely from preventable factors, they lack a structured set of preventive care guidelines. The Affordable Care Act (ACA), enacted in 2010, increased young adult insurance coverage, prohibited copayments for preventive visits among privately insured and for many preventive services. The objectives were to evaluate pre- to post-ACA changes in young adults' past-year well visits and, among those using a past-year health care visit, the receipt of preventive services. METHODS: We used pooled Medical Expenditure Panel Survey data, comparing pre-ACA (2007-2009, N = 10,294) to post-ACA (2014-2016, N = 10,567) young adults aged 18-25 years. Bivariable and multivariable stratified logistic regression, adjusting for sociodemographic covariates, were conducted to determine differences in well visits and in preventive services among past-year health care utilizers: blood pressure and cholesterol checks, influenza immunization, and all three received. RESULTS: Past-year well visits increased from pre-ACA (28%) to post-ACA (32%), p < .001. Increases were noted for most demographic subgroups with greatest increases among males, Asian, and highest income subgroups. Larger pre- to post-ACA increases were found for most of the preventive services, p < .05, including the receipt of all three services (7% vs. 16%), p < .001, among past-year health care utilizers. CONCLUSION: Following ACA implementation, young adults experienced modest increases in well visit rates and larger increases in most preventive services received. Overall rates of both remain low. Building on these improvements requires concerted efforts that account for young adults' unique combination of health care issues and challenges in navigating an adult health care system.

Innovative Approaches to Address Social Determinants of Health Among Adolescents and Young Adults.

Background: Social determinants are the leading causes of health disparities. Yet health care systems have not systemically addressed social determinants of health as it pertains to adolescents and young adults (AYAs), among other populations in need. This study identified promising innovative programs across the United States. Methods: Thirteen representatives from 10 programs completed a 45-min telephone interview. Transcripts were reviewed and analyzed to identify cross-cutting themes. Results: Strategies included increasing access to quality, comprehensive and confidential health services, addressing the holistic needs of AYAs, collaborations across the health care delivery systems and other community services, and leveraging technology. Conclusion: This study showcased innovative approaches to inform future efforts.

Association Between Adolescent Preventive Care and the Role of the Affordable Care Act.

Importance: Despite decades of adolescent preventive well visit and services promotion (Guidelines for Adolescent Preventive Services and Bright Futures), rates are below recommended levels and little is known of the effect of the Patient Protection and Affordable Care Act (ACA) implementation on these care rates. Objectives: To use Medical Expenditure Panel Survey data to determine (1) whether adolescent well visit rates increased from the pre-ACA period to post-ACA period, and (2) whether caregivers' reports of past-year preventive services delivery increased from the pre- to post-ACA period among adolescents with any past-year health care visit. Design, Setting, and Participants: Secondary data analysis of 2007-2009 (before ACA implementation) and 2012-2014 (after ACA implementation) Medical Expenditure Panel Survey data on the differences in well visits and preventive services. Data were collected through computer-assisted personal interviews of caregivers of a nationally representative sample of a noninstitutionalized US population (n = 25 695 10- to 17-year-old adolescents). Main Outcomes and Measures: For objective 1, pre- to post-ACA period differences in past-year well visits: (1) stratified bivariable logistic regressions identifying subgroup rate differences and (2) multivariable analyses controlling for demographic factors. For objective 2, pre- to post-ACA period differences in caregiver reports of preventive services receipt, including time alone with clinician: (1) bivariable (year differences) and (2) multivariable logistic regressions controlling for demographic variables. Results: A total of 6279 (50.9%) and 6730 (50.8%) participating adolescents in the pre- and post-ACA period data were male, respectively. Under objective 1, we found that well-visit rates increased from 41% to 48% post-ACA implementation (odds ratio, 1.3; 95% CI, 1.2-1.5); minority and low-income groups had the greatest increases. Under objective 2, we found that among those with any past-year visit, most preventive services rates (8 of 9) increased post-ACA implementation (range, 2%-9%, absolute), with little or no change when controlling for demographic variables. Time alone with clinicians increased 1%, significant only when covariates were controlled (adjusted odds ratio, 1.2; 95% CI, 1.0-1.3). Conclusions and Relevance: Despite modest to moderate increases, with greatest gains for underserved youth, adolescent preventive care rates remain low, highlighting the need for increased efforts to bring adolescents into well care and improve clinician delivery of preventive care within their practices.

Increasing Delivery of Preventive Services to Adolescents and Young Adults: Does the Preventive Visit Help?

PURPOSE: Despite decades of emphasizing the delivery of adolescent preventive care visits and evidence that many preventive services reduce risk, little evidence links preventive visits to increased preventive service delivery. This study examined whether a preventive healthcare visit versus any nonpreventive healthcare visit was associated with higher rates of adolescent and young adult preventive services. METHODS: Analyzed Medical Expenditure Panel Survey data (2013-2015) to determine whether those with a preventive versus nonpreventive healthcare visit had higher rates of past-year preventive services receipt; adolescents (N = 8,474, ages 10-17) and young adults (N = 5,732, ages 18-25). Bivariable and multivariable analyses adjusting for personal/sociodemographic covariates tested for differences in preventive services rates between preventive versus nonpreventive care groups. Adolescent services were blood pressure, height and weight measured, and all three measured; and guidance given regarding healthy eating, physical activity, seatbelts and helmets, secondhand smoke, dental care, all six topics received, and time alone with provider. Young adult services were blood pressure and cholesterol checked, received influenza immunization, and all three services received. RESULTS: All preventive services rates were significantly higher in those attending preventive visits versus those with nonpreventive visits. Adolescent services increase ranged from 7% to 19% and young adults increase from 9% to 14% (all bivariable and multivariable analyses, p < .001). However, most rates were low overall. CONCLUSIONS: Higher rates of preventive services associated with preventive visits support its clinical care value. However, low preventive services rates overall highlight necessary increased efforts to promote preventive care and improve the provider delivery of prevention for both age groups.