In This Issue

Adolescents Deserve Special Attention in SCHIP Outreach Programs
Public health program administrators and health care policy makers should consider treating adolescents as a distinct group that requires age-specific policies and practices and tailored outreach, benefits and services strategies, according to the National Academy for State Health Policy (NASHP). In its recent Briefing on SCHIP and Adolescents, NASHP noted that adolescents are more likely to be uninsured than younger children and have distinct needs. As has been frequently noted, adolescents are more likely to engage in high-risk behaviors as they get older, and some of those behaviors can affect their health and safety. Additionally, an estimated $700 billion is spent annually on preventable adolescent health problems, particularly with: • Pregnancy • Sexually transmitted infections • Motor vehicle injuries • Substance abuse • Unintentional injuries, and • Mental health problems. According to the U.S. Census Bureau, about 13 percent of adolescents ages 12 through 17 were uninsured in 2006, compared to 11 percent 11 years old or younger. The statistic is even more striking for young people in poverty, the briefing noted. Adolescents also seek office-based health care less frequently than other age groups. As they gain a sense of autonomy, the Academy said, they need to be able to participate more in health care decisions. But, according to the Academy, little is known about how the State Children's Health Insurance Program (SCHIP) particularly serves adolescents, helping them overcome barriers to care. One of the few published studies found that "after uninsured adolescents enrolled in SCHIP, they had increased access to care and improved quality of care, leading to fewer unmet health needs." SCHIP-enrolled adolescents also were more likely to have a single source for health care such as a family physician -- important to receiving preventive services. SCHIP also is associated with reducing racial and ethnic disparities in access to care. SCHIP now enrolls 4.1 million children and adolescents a year, the NASHP authors report, but very few states target adolescents, yet experts believe that outreach programs are essential for getting youth into SCHIP and Medicaid. Since in most states, parents or guardians are the ones who fill out the applications, they too must be targeted. The briefing paper outlines some "best ways" to reach youth and their parents, including: partnering with community sites adolescents frequent, such as schools and malls; training hotline operators and others to answer questions likely to come from adolescents; targeting special populations, such as the homeless, runaways, and minorities; streamlining enrollment procedures, and advertising coverage especially tuned for the needs of adolescents. Administrators should pay special attention to preventive care, mental health services, dental care, and reproductive health. Confidentiality is crucial, the authors note, as many adolescents will seek health care on the condition that their privacy will be honored. SCHIP programs should take into account the state laws that allow adolescents to consent for their own care under specific circumstances. Because SCHIP incorporates both the program components and flexibility needed to reach and enroll adolescents, it has shown some success in serving adolescents during its first decade. More effort, the report urges, would be effective. The State Health Policy Briefing may be found at http://www.nashp.org/Files/shpbriefing_adolescents.pdf.
Increase in Obesity Among American Young is Leveling Off
The seemingly inexorable increase in the percentage of obese children in the U.S. appears to have flattened out, according to a new study, published in the current Journal of the American Medical Association. According to the authors, it is not clear whether the change is the beginning of a new trend or a statistical artifact. According to the study by researchers at the National Center for Health Statistics of the Centers for Disease Control and Prevention (CDC), the proportion of 2-to-19 year olds who are overweight has stopped rising for the first time since the 1980s. The percentage of high BMI for age among children and adolescents showed no significant changes between 2003-2004 and 2005-2006, according to Cynthia L Ogden and her colleagues. Even if the leveling off continues, the prevalence of overweight among American children remains high, and that could mean years of serious health problems as they grow older. The study included weight and height measurements from a sample of 8,165 children collected as part of the 2003-2004 and 2005-2006 National Health and Nutrition Examination Surveys. The measurements were converted to a body weight index (BMI), the weight in kilograms divided by height in meters squared, the common metric for categorizing weight. Obesity is defined as having a BMI at or above the 95th percentile on growth charts. In the 1960s and 1970s, only 5 percent of children in the United States were obese. The figure now is 15.5 percent. Overweight is defined as the 85th percentile. Currently, 31.9 percent of American children qualify as either obese or overweight, and 11.3 percent were above the 97th percentile, characterized as very obese. The good news is that there is no statistically significant change in those figures since 1999, which leads the researchers to conclude that the plateau may be real and not a temporary pause. Additionally, the flat results cut across gender, race and ethnic lines, although older non-whites continued to have higher rates of obesity than did whites. The research did not explore why the increase has halted. Words of caution were provided in a JAMA editorial by Cara B. Ebbeling and David S. Ludwig. They pointed out that BMI may not necessarily be the best measure for characterizing weight issues or in predicting future health problems. "Historical cohort studies document an association between childhood BMI and chronic disease in childhood,” they wrote, “but optimal levels of BMI for long-term health are not known." "It is too early to know whether these data reflect a true plateau or a statistical aberration in an inexorable epidemic, and pre-existing racial/ethnic disparities show no sign of abating," they wrote. "On one point there is no uncertainty: without substantial declines in prevalence, the public health toll of childhood obesity will continue to mount, because it can take many years for an obese child to develop life-threatening complications." The journal article may be found at http://jama.ama-assn.org/cgi/content/full/299/20/2401. The editorial may be found at: http://jama.ama-assn.org/cgi/content/full/299/20/2442. Meanwhile, a study published in the June issue of Pediatrics, put part of the blame for overweight teenagers on their parents. The report, by researchers at the University of Minnesota, said that while parents can recognize that their teenage children are overweight and talk about dieting, they do not encourage “healthy things” at home to encourage weight management, such as changing diets and increasing their children’s physical activity. Encouraging dieting alone produced poorer weight outcomes over five years, the researchers said.
Minor Consent Laws Are Imperative for Adolescents But Accidental Breaches in Privacy Still Occur
In every state, a person below the age of consent cannot make their own decisions about health care without the permission of their parents for most medical procedures, but state and federal laws carve out exceptions for sensitive services, commonly called minor-consent laws. With these exceptions come promises of confidentiality, wrote Harriette B. Fox and Stephanie J. Lamb of Incenter Strategies, in a fact sheet, State Policies Affecting the Assurance of Confidential Care for Adolescents, published by the National Alliance to Advance Adolescent Health. The study enumerates the variations in state minor-consent laws and discusses an administrative practice that can lead to breaches in confidentiality.. As is widely understood, confidentiality of medical records is considered vital to serving adolescents because securing parental consent is difficult in some circumstances, and in other instances impossible for fear of embarrassment, disapproval, or even punishment, the authors wrote. If adolescents are sure of confidentiality, they would be more inclined to seek needed health care. For instance, data show that requiring parental consent for birth control discourages adolescents from seeking family planning services but not from having sex. The report's analysis of state statutes shows that "27 states allow some minors the right to consent independently for general medical care." Twenty-three states permit minor consent only for adolescents who meet specific criteria, which, depending on the state, might include adolescents who are high school graduates, serving in the military, pregnant, married or legally emancipated from their parents. All states allow minor consent, typically for adolescents 12 or older, for at least one service. Minor consent for STD services is permitted in all states, although the age of consent is 14 in five states, and 16 in one. Minor consent for substance abuse treatment is authorized in the vast majority of states, but for family planning services and for outpatient mental health services, is permitted in only about half the states. Federal law permits minors to consent to some types of family planning services without parental consent at federally funded family planning clinics when services are being reimbursed by Medicaid. "Importantly, however, even where parental notification is not required, the right to consent independently for services is not sufficient to guarantee confidentiality," the report noted. "Administrative and billing practices used by Medicaid and private insurers may eviscerate the confidentiality protections made possible by minor consent laws," the authors wrote. The major problem is the practice of mailing explanation of benefits (EOB) statements to publicly insured individuals or privately insured policyholders. The EOBs usually contain a description of the services, the date and the provider's identity. Practices vary, the study found. Commercial insurers are required in almost every state to mail EOBs to the policyholder. State Medicaid programs are usually not required to do so, but the survey found that states do send them for fee-for-services recipients while managed care organizations (MCOs) usually do not. Practices in the State Children's Health Insurance Program (SCHIP) vary, depending on the type of program. "In nearly all states, the confidentiality of Medicaid-insured adolescents would be compromised if either the MCOs in which they were enrolled or the Medicaid agencies themselves mailed EOBs home," the report said. Breaches in confidentiality are less frequent, the survey found, for patients in MCOs, as the MCOs usually have the option not to do mailings and most do not. One state, Minnesota, forbids the mailings for sensitive services. Medicaid-served adolescents enrolled in primary care case management systems or who are on a fee-for-service basis are more likely to have their confidentiality violated. State Medicaid agencies have discretion in whether to mail the EOBs, and the survey found that most do, and a few are required to do so by law. The most common reason offered for the practice is that it ensures that the state is in compliance with federal regulations to combat fraud. Mailing EOBs is not specifically required by the federal legislation, but the states view mailings as an inexpensive and simple way to verify services. The authors said there are other strategies that would not threaten privacy and would be more efficient. "To maintain confidentiality protections afforded under federal and state law, the services for which minors are able to consent should need to be excluded from EOB mailings by states and participating MCOs," the authors said. Only Florida has done so. The full report may be downloaded in pdf format from http://www.thenationalalliance.org/jan07/factsheet5.pdf.