Fact Sheet: Impact of the ACA on Vulnerable Youth

Abigail English, JD, Center for Adolescent Health & the Law

Jazmyn Scott, MPH, and M. Jane Park, MPH, NAHIC, University of California San Francisco

Implementation of the Affordable Care Act (ACA) will have
major implications for specific populations of vulnerable
youth. Three groups that are certain to be affected are youth in
and aging out of foster care, youth involved in juvenile and
criminal justice systems, and homeless youth. This fact sheet is
adapted from a more detailed brief that discusses
demographics, health status, and health care access, both pre-
and post-ACA, for each of the three groups, entitled
Implementing the Affordable Care Act: How Much Will It Help
Vulnerable Adolescents & Young Adults?

Several common themes characterize these three populations.
Many of the young people in each of these groups will gain
access to health insurance as the ACA moves forward, while
others may be left behind. Important challenges must be
overcome to ensure that the ACA improves health care access
for as many of these vulnerable youth as possible.

"Significant overlap among the three groups. Many youth
become homeless or are arrested after exiting foster care.
Many youth who are arrested and processed through the
juvenile justice system are placed in foster care facilities,
such as group homes or residential treatment centers.
Many homeless youth were either in foster care or have
been arrested or involved in the juvenile or criminal
justice system.

= Overrepresentation of racial and ethnic minorities. Without
exception, all three vulnerable populations comprise
members of racial and ethnic minority groups at
disproportionately high rates, with African American
young people especially heavily represented among all
three populations.

® Higher rates of serious health problems than the general
population. The three groups’ health problems extend
across the full spectrum of health concems of adolescents
and young adults. Mental health, substance abuse, and
sexual health issues are of particular concern.

* High rates of being uninsured and heavy reliance on Medicaid.
With the exception of adolescents in foster care, who are
mostly covered by Medicaid, youth in all three groups are
either uninsured at high rates, sometimes approaching
50%, or are at high risk of losing insurance. All are more
likely to secure health insurance coverage through
Medicaid than private health insurance.

"Disconnection from familial, adult, and social support. Most of
the vulnerable youth in all three groups are seriously
lacking in connections to and support from parents, family

members, other adults, and social institutions. Even those
with a connection to the child welfare or juvenile or
criminal justice system often lack meaningful supportive
adult connections.

Until now, many youth in foster care were eligible for
Medicaid, but lost coverage when they aged out. Beginning in
2014, the ACA requires all states to provide Medicaid coverage
for most youth aging out of foster care until the age of 26. This
parallels the ACA provision allowing young adults to remain
ona parent's health insurance policy to age 26, which has
resulted in about three million young adults gaining private
health insurance.

According to the proposed federal regulation to implement the
provision for former foster youth, states must provide
Medicaid coverage to individuals who are under age 26, are
not otherwise eligible for and enrolled in Medicaid, and were
in foster care and enrolled in Medicaid when they reached age
18 (ora later age for aging out of foster care, as specified by
their state). There are no financial eligibility (“income or
resources”) requirements for a former foster youth to qualify
for this Medicaid coverage; former foster youth who meet the
other requirements may apply at any time up to age 26. The
federal government has estimated that by 2017 an additional
74,000 former foster youth will be enrolled in Medicaid under
this provision.

The ACA, as written, limits the required coverage to former
foster youth applying for Medicaid in the state in which they
had been in foster care. However, the proposed regulation
would allow states to offer the coverage to youth who had.
been in foster care in any state, but would not require them to
do so,

Access to health insurance for youth involved in the juvenile or
criminal justice systems is likely to depend largely on whether
they live in a state that chooses to implement the ACA
Medicaid expansion. This is true because so many of these
youth are living in poverty or have very low incomes.

The ACA gives states the option of expanding Medicaid to
most individuals under age 65 with incomes below 133% FPL
(or 138% including income disregards). The ACA also requires
states to provide Medicaid coverage for all children and
adolescents through age 18 up to 133% FPL. Thus, adolescents
under age 18 involved in the juvenile justice system will be
eligible for Medicaid if their family incomes are below 133%
FPL, as long as they are not confined in secure facilities that
meet the definition of “public institution.” Medicaid eligibility
for young adults over the age of 18 involved in the criminal


Fact Sheet: Impact of the ACA on Vulnerable Youth

justice system will depend on whether they are incarcerated in
a public institution and on whether they live in a state that
implements the Medicaid expansion.

In states not implementing the expansion, young adults may
be left without viable options for coverage: most of these states
offer no Medicaid coverage for single adults without
disabilities or who are not parents of dependent children. The
young adults may also come from uninsured families and be
unable to afford private coverage themselves, especially since
they will not qualify for a subsidy in the ACA marketplaces, if
their incomes are below 100% FPL.

Whether the ACA helps homeless youth, especially homeless
young adults, join the ranks of the insured will also depend to
a great degree on whether they ate in a state that has chosen to
expand Medicaid. Also important will be whether the
application and enrollment obstacles, such as having a
permanent address, which have stood in the way in the past,
are removed. Although some homeless youth are employed,
the vast majority have very low incomes or none at all and
would almost certainly be eligible for Medicaid in states that
implement the Medicaid expansion. In states that do not
expand Medicaid, their options will be limited. Coverage to
age 26 on a parent's policy is not a viable option for youth
disconnected from their families. Virtually no homeless youth
would have income sufficient to purchase an individual policy
through the ACA state insurance marketplaces. For many
homeless youth, the application and enrollment procedures
either in Medicaid or the marketplace, particularly the
requirement of a permanent address, as well as documentation
requirements, would stand in the way of securing coverage.

In short, two obstacles could prevent many vulnerable youth
from securing health insurance coverage as the ACA is
implemented. The first is the failure of half the states to expand
Medicaid. The second is the complexity of the application and
enrollment process.

As of October 22, 2013, 25 states and the District of Columbia
had opted to implement the Medicaid expansion. In states
implementing the option, more vulnerable young people will
qualify for Medicaid. The implications for vulnerable groups in
states that choose not to implement the Medicaid expansion
will be severe. All but one of these states do not offer any
Medicaid coverage to single adults unless they are pregnant,
parents of dependent children, or have a disability, In these
states, homeless youth and those involved in the justice
systems are at high risk for remaining uninsured once they
reach age 18.

Even those youth who are eligible for Medicaid or able to
purchase coverage through the ACA insurance marketplaces
may encounter obstacles: the complexities associated with
application and enrollment could prevent some from gaining
coverage. The ACA includes two requirements that could be
important in this regard. First, states are required to conduct
outreach to and enroll in Medicaid and CHIP vulnerable and
underserved populations, including unaccompanied homeless
youth. Second, states are required to have streamlined
application procedures and to provide assistance with
enrollment through “navigators.”

Youth in and aging out of foster care and the juvenile and
criminal justice systems as well as homeless youth all have
serious health care needs that could be met with services
available in Medicaid or the plans offered through the health
insurance exchanges. Many of these young people will qualify
for Medicaid or other coverage as a result of the ACA; many
will not. Those who are left out will have unmet health care
needs that present challenges for them, their families, their
communities, and society at large.

Note: Supporting references are contained in the more detailed
brief Implementing the Affordable Care Act: How Much Will It Help
Vulnerable Adolescents & Young Adults?, which this fact sheet is
based on.

Center for Adolescent Health & the Law
National Adolescent and Young Adult Health Information Center
January 2014


Fact Sheet: Impact of the ACA on Vulnerable Youth

Center for Adolescent Health & the Law
PO Box 3795

Chapel Hill, NC 27515-3795

ph, 919.968.8850

e-mail: info@cahl.org

hitp://www.cahlorg

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

£, 415.502.4858

email: nahic@ucsf.edu
http://nahic.ucsf.edu

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 and young adults 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.

Suggested Citation

English A, Scott J, Park Mi. Fact Sheet: Impact of the ACA on
Vulnerable Youth. Chapel Hill, NC: Center for Adolescent Health &
the Law; and San Francisco, CA: National Adolescent and Young
Adult Health Information Center, 2014.

Issue Briefs in This Series

English A, Scott J, Park MJ. Implementing the ACA: How Much Will It
Help Vulnerable Adolescents & Young Adults? Chapel Hill, NC:
Center for Adolescent Health & the Law; and San Francisco, CA:
National Adolescent and Young Adutt Health Information Center,
2014.

English A, Park MJ. The Supreme Court ACA Decision: What Happens
Now for Adolescents and Young Adults. Chapel Hill, NC: Center for
Adolescent Health & the Law; and San Francisco, CA: National
Adolescent and Young Adult Health Information Center, 2012.

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 Health Information and Innovation Center, 2012.

English A. The Patient Protection and Affordable Care Act of 2010:
How Does It Help Adolescents and Young Adults. Chapel Hill, NC:
Center for Adolescent Health & the Law; and San Francisco, CA:
National Adolescent Health Information and Innovation Center,
2010.

Acknowledgments

The authors gratefully acknowledge the contributions of their
colleagues Claire D. Brindis and Charles E. Irwin, Jr. at NAHIC, and
Trina Anglin at the Maternal and Child Health Bureau for their
thoughtful reviews of this brief.

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 (U45MC 00002 and U4SMC 00023). Additional
support was provided by the Brush Foundation and by individual
donors to the Center for Adolescent Health & the Law.

Center for Adolescent Health & the Law
National Adolescent and Young Adult Health Information Center
January 2014