The elusive patient: Getting twentysomethings into the health care system

Young adults share many health risks with adolescents but have less access to care.

By Victoria Stagg Elliott — Posted May 14, 2007

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A few years ago, Gail Martin, MD, a Kaiser Permanente family physician in Oakland, Calif., noticed that when her young adult patients graduated from pediatrics, they didn't seem to know where to go. This observation inspired her to set up a clinic for 18- to 24-year-olds.

"These young adults weren't getting what they needed," Dr. Martin said. "We developed a mission and an approach to take care of these patients and address what may be going on in their lives."

Emphasis was placed on the biggest causes of mortality and morbidity for this age group. Also, efforts were made to reduce the need for return visits, because it became clear that these patients are less likely to be able to make it to a doctor's office because of work and school schedules.

The results have been positive. According to surveys, the clinic increased patient satisfaction. In addition, screenings such as for cervical cancer and sexually transmitted infections went up. The facility, which has a dozen physicians on staff, is expanding to 16. And the HMO plans to establish similar clinics at other locations.

Obviously, Dr. Martin is not alone in trying to reach this demographic. Many physicians and health policy experts now recognize that the risks of adolescence do not stop at age 18. Instead, they actually get worse -- a circumstance amplified by the fact that young adults have few resources for support. A July 2006 National Institute for Health Care Management report termed young adult health care a "national imperative," and efforts to improve adolescent health are increasingly being expanded to include this population.

"This is the time when young people slip through the cracks," said Richard Heyman, MD, chair of the American Academy of Pediatrics section on adolescent health. "There's been a fairly significant push in the area of adolescent health over the last decade and a lot of attention paid to teenagers, but the question is, what happens after they turn 18?"

According to a September 2006 review article in the Journal of Adolescent Health, the mortality rate nearly triples from adolescence to young adulthood. Smoking increases from 12% to 40%. Binge drinking goes up from 11% to 42%. Sexually-transmitted diseases and substance abuse become more common, and mental illnesses may make their first appearance.

What safety net?

But while their health threats become more serious, access to medical care decreases. This age group has the highest rate of uninsurance because its members no longer qualify for public programs or their parents' insurance. They also have the highest rate of poverty and are least likely to have employer-sponsored coverage.

"All the issues that we care about the most -- that the adolescent medicine and health field focuses on -- it all gets worse in young adulthood," said Jane Park, MPH, lead author and policy research coordinator in the division of adolescent medicine at the University of California, San Francisco. "And there's much less national infrastructure that supports this age group."

As is the case for others who lack insurance, the result for these postadolescents often is care delayed or deferred. According to a study in the July 2005 Pediatrics, young adults without insurance were more likely than insured peers to have no contact with the health care system and to go without a usual source of care.

"We need to create other opportunities for young adults to obtain health insurance coverage through their employer or through their schools or through other means that will allow them to gain not only coverage but stable coverage throughout their young adult years," said Todd Callahan, MD, MPH, that paper's lead author and an assistant professor of pediatrics at Vanderbilt University Medical Center in Nashville, Tenn.

Experts suspect that this care gap has developed because health policy has not kept up with changes in the lives of young adults. This age has become a time of transition with people getting married later than in previous generations. More also are pursuing a college degree before entering the work force.

"They really are in a tough bind," said Michelle Forcier, MD, MPH, clinical practice director for adolescent medicine at Children's Memorial Hospital in Chicago. "And both the medical system as well as other social services really haven't built the appropriate safety net to provide care as they continue to transition from child to youth to young adult to a capable, able functioning adult person in our society."

Although more young adults attend college than ever before, and this affords them some medical system access, many experts do not view this as the solution. Care in that setting is not comprehensive and often is not available year-round. Also, many young adults don't continue their educations and have even less access to care.

"That's the group that I worry about in terms of being uninsured," said Lynne Kirk, MD, immediate past president of the American College of Physicians.

To increase access, more public programs that provide insurance for children and adolescents are raising their cutoff ages. Private insurers also have launched plans for this age group. Several medical societies, including the American Medical Association, have policy calling for family insurance plans to raise the age for dependent children. And many insurers have volunteered or been mandated by state law to do so.

"Young adults are actually a pretty inexpensive population to insure," said Robert Flaherty, MD, a family physician at Montana State University's student health service in Bozeman. "They don't have chronic diseases. Most of their illnesses and medical conditions are either related to trauma or pregnancy. I would think that low-cost insurance would be really possible in this group."

But experts say the solution goes beyond simply increasing insurance access. Many young adults might not believe they have health care needs and are not yet concerned about prevention. For them, health insurance is not a budget priority. Moreover, it is difficult to link with this group, because no one institution -- such as high school for adolescents -- serves as a focal point.

"If I were to suddenly give everybody a gold insurance card that allowed them to come in and see their health care provider at no cost, I don't think that we would suddenly have a long line of young adults waiting at the door," said David S. Rosen, MD, MPH, professor of pediatrics and internal medicine at the University of Michigan.

Many experts also suspect there may be more that is unknown about the lives and mentality of young adults that translates to a lack of connection with the health care system. In particular, physicians are struggling to attract young men. Women tend to have regular physician contact because of reproductive issues. Men have no such draw.

"There is a need and an opportunity to figure out within the medical community how best to approach guys," said David Bell, MD, MPH, medical director of the Young Men's Clinic run by Columbia University's Mailman School of Public Health and New York Presbyterian Hospital. "Once we have more technologies that speak to what young men are interested in, that may be more of a draw."

A puzzle to figure out

Physicians who work with this group also say there is an urgent need for care guidelines, and many suggest these could be modeled on the AMA's Guidelines For Adolescent Preventive Services or the AAP's Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Dr. Martin and her colleagues plan to develop a set for Kaiser Permanente, and some are in pursuit of an even broader reach.

Directives are particularly key because many physicians want guidance on attempts to prevent the suicides, homicides and unintentional injuries that are this demographic's biggest killers. Physicians also would like to maximize chances for preventive care. Finally, with a growing number of vaccines for adolescents, the young adult period is seen as a key catch-up time.

"These are folks on the cusp of really taking charge of their lives. With a little bit of support and resources, we could potentially encourage them to move their lives in a really healthy direction," Dr. Forcier said.

Significant concern continues, too, about access to care for the subgroup of young adults who have chronic conditions or need significant acute care. These health issues can be catastrophic and financially cripple individuals at the beginning of their journey to economic independence.

"They are a relatively healthy population, but they're also a population that can be devastated by an unintentional injury," Dr. Callahan said. "It is going to take a concerted effort by physicians in a wide variety of specialties to improve health care for young adults. It's also going to take efforts on behalf of policymakers, both local and national, and young adults themselves and the people who care about them, to really make health care better for this age group."

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Who is uninsured when

[download pdf]

Lack of insurance is a challenging aspect of providing care for patients between ages 18 and 24. Here is how this age group compared with other groups younger than 65 in 2004, the latest year surveyed.

Age Uninsured more than a year Uninsured less than a year
than 18
5.4% 6.3%
18-24 19.9% 14.8%
25-34 18.1% 11.7%
35-44 13.0% 6.7%
45-54 10.1% 5.0%
55-64 8.7% 3.7%
Average 11.4% 7.6%

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey

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What kills young adults

Those who are 18 to 24 years old are generally healthy but prone to risky behaviors, especially so for young men. These behaviors generally tie in to the major causes of premature deaths, and a jump in mortality rates after adolescence. Here is how this age group compares with teenagers:

Overall mortality per 100,000:

Male Female
12-17 18-24 12-17 18-24
All causes 47.1 137.0 24.3 49.3
Suicide 5.3 19.2 1.6 3.3
Homicide 5.7 27.0 1.1 4.6
Unintentional injuries 21.7 62.0 11.5 20.7
Other causes 14.3 28.7 10.0 20.7

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External links

The Network on Transitions to Adulthood, MacArthur Foundation (link)

Public Policy Analysis & Education Center for Middle Childhood, Adolescent & Young Adult Health, University of California, San Francisco (link)

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