Department of Health and Human Services

Office of the Assistant Secretary for Planning and Evaluation

http://aspe.hhs.gov

ASPE

RESEARCH BRIEF

THE AFFORDABLE CARE ACT AND ADOLESCENTS

By:

Diane Pilkey, Laura Skopec, Emily Gee, Kenneth Finegold, Kerent Amaya, ASPE

and Wilma Robinson, Office of Adolescent Health

Over 42 million adolescents (ages 10 to 19) live in the United States, making up roughly 14 percent of all 

Americans.1

 About 9.8 percent of youth ages 12-17 lack health insurance.2 The health care needs of 

adolescents are different from those of adults and children. Although adolescents are generally healthy, 

access to health care, preventive care, and health education is important to ensure continued health 

throughout their lives.3 The behavioral patterns established during the second decade of life help 

influence not only the current health status of adolescents, but their risk for developing chronic diseases 

into adulthood. For example, adolescents who are obese are more likely to be obese as adults and are 

therefore more at risk for adult health problems such as heart disease, type 2 diabetes, stroke, several 

types of cancer, and osteoarthritis.4

 In addition, there are significant disparities in outcomes among 

racial and ethnic groups for adolescents. In general, adolescents and young adults who are African 

American, American Indian or Alaska Native, or Latino, especially those who are living in poverty, 

experience worse outcomes in a variety of areas (obesity, teen pregnancy, tooth decay, and educational 

achievement) compared to adolescents who are White or who are more economically advantaged.

4

 

An estimated 9.8 percent of adolescents ages 12-17 lack health insurance and 4.7 percent have no usual 

source of health care.

2 Adolescents are worse off than younger children in both respects.5 The 

Affordable Care Act includes several provisions that are expected to improve health and access to 

healthcare for adolescents. An estimated 4.2 million uninsured adolescents ages 10-19 will be eligible to 

 1 American Community Survey 2011. Accessed August 2013 at: 

http://factfinder2.census.gov/faces/nav/jsf/pages/searchresults.xhtml?refresh=t

2 Summary Health Statistics for U.S. Children: National Health Interview Survey, 2011. Virtual and Health Statistics

10(254), December 2012.

3 National Conference of State Legislatures. The Affordable Care Act: Implications for Adolescents and Young 

Adults. October 2011. Accessed August 2013 at: 

http://www.ncsl.org/portals/1/documents/health/HRAdolescents.pdf

4 Adolescent Health. U.S. Department of Health and Human Services, 2013. Accessed August 2013 at: 

http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=2). 5 Lindsey Jeanne Leininger and Marguerite E. Burns, “Why are Low-Income Teens More Likely to Lack Health 

Insurance Than Their Younger Peers?,” Inquiry 48 (2011): 123-137; Marguerite E. Burns and Lindsey Jeanne 

Leininger, “Understanding the Gap in Primary Care Access and Use Between Teens and Younger Children,” Medical 

Care Research Review 69 (2012): 581-601.
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gain health care coverage under the Affordable Care Act beginning January 1, 2014.

6 While states have 

new opportunities to expand Medicaid eligibility for adults (including adolescents ages 19 and older)

with income up to 133% of the Federal Poverty Level (FPL), all states must cover children up to age 19 

with family incomes below 133% of the FPL through the Medicaid program.7 About 40 percent of these 

eligible uninsured (U.S. citizens and legal immigrants) adolescents are non-Latino White, 35 percent are 

Latino, and 16 percent are non-Latino African American (Table 1). An estimated 2.2 million (53 percent) 

are male and 1.9 million are female, and 776,000 (19 percent) live in rural areas of the United States

(data not shown). The estimated share of youth ages 10-19 that are eligible uninsured varies from 2.3 

percent in Massachusetts to 17.8 percent in Texas (Figure 1). 

Table 1: United States Eligible Uninsured Ages 10-19 By Race and Ethnicity, 20116 

Race/Ethnicity Total

Number

Percentage of

Eligible Uninsured

White (Non-Latino) 1,691,000 40.3%

Latino 1,464,000 34.9%

African American (Non-Latino) 649,000 15.5%

Asian (Non-Latino) 178,000 4.3%

Multiracial 126,000 3.0%

American Indian/Alaskan Native 76,000 1.8%

Hawaiian/Pacific Islander 7,000 0.2%

Total 4,192,000 100.0%

 

 

6 ASPE tabulations from the CY 2011 ACS Public Use Microdata Sample were adjusted to exclude estimated 

undocumented persons based on imputations of immigrant legal status in ASPE's TRIM3 microsimulation model. 

Includes currently eligible but not enrolled and those newly eligible in 2014.

7 Section 2002 provides for an income disregard of 5 percent of Federal Poverty Guidelines, raising the effective 

income limit to 138 percent.
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ASPE Office of Health Policy August 2013

 

Figure 1: Percentage of Youth Ages 10-19 That Are Eligible Uninsured by State, 20116

Select Coverage and Benefits Provisions of the Affordable Care Act

The Affordable Care Act includes provisions intended to improve access to health insurance coverage 

and ensure that such coverage provides essential health benefits for adolescents and young adults. 

Several of these provisions are already in effect for most plans, including requirements to cover 

preventive services without cost-sharing, a prohibition on pre-existing condition exclusions for children 

under age 19, a prohibition of lifetime or restrictive annual limits on essential health benefits, and 

coverage for dependents ages 19-25 on their parent’s health insurance plan. Several others, including 

the opportunity for states to expand Medicaid, coverage of essential health benefits, and the ability to 

get coverage through the new Health Insurance Marketplace with access to premium tax credits will 

apply for plan years beginning on or after January 1, 2014. Taken together, these provisions ensure that 

adolescents will have access to health insurance that covers benefits particularly important for this 

population. 

Preventive Health Services with No Co-Pay

Health promotion, disease prevention, early intervention, and timely treatment of conditions can 

improve the health status of adolescents and reduce the incidence of chronic conditions in adulthood. 

The Affordable Care Act (adding new Section 2713 to the Public Health Service Act) seeks to make 

prevention affordable by requiring most private health insurance plans to cover recommended 

preventive services without cost-sharing, meaning not subject to deductibles or co-pays/coinsurance. 

The Affordable Care Act identified specific sources for these recommendations for preventive services, 

including the United States Preventive Services Task Force’s recommendations with an “A” or “B” rating, 
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ASPE Office of Health Policy August 2013

the Advisory Committee on Immunization Practices, and guidelines supported by the Health Resources 

and Services Administration (such as Bright Futures for children and adolescents and the guidelines for 

women’s clinical preventive services). Recommended preventive services and screenings are now 

covered with no out-of-pocket costs, including immunizations, behavioral assessments for adolescents, 

obesity screening, FDA-approved contraception and patient education counseling, and sexually 

transmitted infection (STI) prevention counseling and screening for sexually active adolescents. In a 

national survey, about ten percent of youth ages 12-17 reported any illicit drug use in the past month 

and eight percent reported cigarette use in the past month.8

 An estimated 31 percent of children ages 

10-17 are overweight or obese.

9 Teenagers are more likely to have an unintended pregnancy than 

older females. Among women ages 19 and younger, more than 4 out of 5 pregnancies are unintended.10

Prohibition of pre-existing conditions denials

An estimated 25 percent of all children between the ages of 12 and 17 have special health care needs.

For example, about 11 percent of adolescents 12-17 have Attention Deficit Disorder/Attention Deficit 

Hyperactivity Disorder (ADD/ADHD) and 10 percent have asthma.

9 The Affordable Care Act (adding new 

Section 2704 to the Public Health Service Act) prohibits denial of coverage for pre-existing conditions. 

For plan or policy years beginning on or after September 23, 2010, group health plans, group health 

insurance coverage, and non-grandfathered individual health insurance policies may not deny or limit 

coverage for children under the age of 19 because of a pre-existing condition. For plan or policy years 

beginning on or after January 1, 2014, group health plans, group health insurance coverage, and nongrandfathered individual health insurance policies may not deny or limit coverage for any enrollee 

because of a pre-existing condition. 

Dependent Coverage Expansion

As of September 23, 2010, the Affordable Care Act (adding new Section 2714 to the Public Health 

Service Act) and its implementing regulations provide that new or renewing plans in the individual and 

group markets are required to cover dependents ages 25 and younger if they offer dependent coverage. 

This applies to young adults even if they are married, not living with their parent and/or not financially 

dependent on their parent. Grandfathered group health plans may exclude coverage of a dependent 

that has access to eligible employer-sponsored coverage. As of December 2011, 3.1 million young adults 

(ages 19-25) had gained coverage under this provision.11

Medicaid/ Children’s Health Insurance Program (CHIP)

The Affordable Care Act (Section 2001) requires maintenance of the pre-Affordable Care Act Medicaid 

and CHIP eligibility levels for children 18 and younger through 2019. In addition, the Affordable Care Act

requires all states to provide Medicaid coverage for children ages 6-18 with incomes at or below 133

percent of Federal Poverty Level Guidelines beginning January 1, 2014. Beginning January 1, 2014, the 

Affordable Care Act (Section 2004) also generally makes current and former children in foster care 

eligible for Medicaid until they turn 26.

 8 National Survey on Drug Use, 2010-2011. Accessed August 2013 at: 

http://www.samhsa.gov/data/NSDUH/2k11State/NSDUHsae2011/Index.aspx

9 Based on parental reporting. National Survey of Children’s Health, 2011-2012. Accessed August 2013 at: 

http://www.childhealthdata.org/browse/survey

10 Centers for Disease Control and Prevention. Unintended Pregnancy Prevention. Accessed August 2013 at: 

http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/index.htm

11 ASPE Issue Brief. Number of Young Adults Gaining Insurance Due to the Affordable Care Act Now Tops 3 Million.

June 19, 2012. Accessed August 2013 at: http://aspe.hhs.gov/aspe/gaininginsurance/rb.shtml
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Essential Health Benefits

For plan or policy years beginning on or after January 1, 2014, non-grandfathered individual and small 

group market insurance plans must cover benefits in ten categories of services and items included in the 

definition of essential health benefits (EHBs). The ten categories include: ambulatory patient services; 

emergency services; hospitalization; maternity and newborn care; mental health and substance use 

disorder services, including behavioral health treatment; prescription drugs; rehabilitative and 

habilitative services and devices; laboratory services; preventive and wellness services and chronic 

disease management; and pediatric services, including oral and vision care (Section 1302 of the 

Affordable Care Act and Section 2707(a) of the Public Health Service Act). In addition, the Affordable 

Care Act prohibits annual and lifetime limits on coverage of essential health benefits.

Some benefits particularly relevant to adolescents include:

• Pediatric dental and vision services must be offered for children up to age 19. Based on the 2011-

2012 National Survey of Children’s Health, an estimated 19 percent of adolescents ages 12-17 had 

oral health problems in the 12 months prior to the survey and 2 percent had vision problems.9

• Habilitative services are particularly relevant for children and adolescents with developmental 

disorders.

• Mental health and substance use disorder services, including behavioral health treatment, are 

subject to federal parity requirements. Based on the 2010-2011 National Survey on Drug Use and 

Health, about 994,000 youth ages 12-17 (4 percent) needed but did not receive treatment for 

alcohol use in the past year and 1,070,000 youth (4.3 percent) needed but did not receive treatment 

for illicit drug use in the past year.12

Health Insurance Marketplaces

The Health Insurance Marketplace will provide a new, simplified mechanism to obtain coverage in the 

individual market beginning in 2014. Families with household incomes between 100 to 400% of the 

Federal Poverty Level (FPL) who are not eligible for Medicaid or CHIP may qualify for new tax credits to 

make premiums more affordable. In addition, any plan available to adults must be available for childonly enrollment for children under the age of 21. Open enrollment begins on October 1, 2013 for 

coverage as soon as January 1, 2014.

Other Relevant Affordable Care Act Initiatives

In addition to coverage and benefit provisions, the Affordable Care Act includes several other provisions 

aimed at improving health and healthcare access among adolescents. These include funding for schoolbased health centers, teen pregnancy prevention programs, home visiting programs, a childhood obesity 

demonstration project, and the expansion of community health centers. 

School-Based Health Centers

School-based health centers provide medical care, mental health services, and oral health care and / or 

preventive services through nearly 2,000 schools nationally.

13 The Affordable Care Act (Section 4101) 

appropriated funds to school-based health centers to address capital needs. Through this grant 

program, the Department of Health and Human Services (HHS) provided $200 million in 2010-2013 for 

construction, renovation, and equipment. By December 2012, a cumulative total of 520 awards were 

 12 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2010 and 2011. 

Accessed August 2013 at: http://www.samhsa.gov/data/NSDUH/2k11State/NSDUHsaeCountTabs2011.htm 13 HRSA, School-Based Health Centers. Accessed August 2013 at: 

http://www.hrsa.gov/ourstories/schoolhealthcenters/
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made in 47 states, the District of Columbia, and Puerto Rico. Information is available at 

http://www.hrsa.gov/ourstories/schoolhealthcenters/.

Teen Pregnancy Prevention

In 2011, the teen birth rate for ages 15-19 was 31.3 live births per 1,000 population, or 329,797 births. 

This is the lowest rate since 1991; however, disparities in teen birth rates persist. In 2011, the teen birth 

rate for Latinos was 49.4 per 1,000, 47.4 per 1,000 for Non-Latino African Americans and 36.2 per 1,000 

for American Indian and Alaska Natives, compared to a rate of 21.8 per 1,000 for Non-Latino Whites and 

10.2 per 1,000 for Asian American and Pacific Islander teens.

14

The Affordable Care Act supported continuing efforts to prevent teen pregnancy through three 

programs cited in the Act:

• Personal Responsibility Education Program (PREP). This program created by the Affordable Care Act

(Section 2953) is administered by the Administration for Children and Families (ACF) at HHS. PREP 

projects are required to replicate effective, evidence-based program models or substantially 

incorporate elements of projects that have been proven to delay sexual activity, increase condom or 

contraceptive use for sexually active youth, or reduce pregnancy among youth. The programs must 

be medically accurate and place substantial emphasis on both abstinence and contraception for 

preventing pregnancy and sexually transmitted infections. Fifty-two states and territories received 

funding in FY 2012. Information is available at:

http://www.acf.hhs.gov/programs/fysb/resource/prep-fact-sheet.

• Abstinence Education. The Affordable Care Act (Section 2954) restored funding for the Title V State 

Abstinence Education Grant Program (AEGP) administered through ACF, providing funding to States 

and territories for abstinence education, and where appropriate, mentoring, counseling, and adult 

supervision to promote abstinence from sexual activity. Projects focus on those groups at risk for a 

teen pregnancy. Thirty-nine states and territories received funding in FY 2012. Information is 

available at: http://www.acf.hhs.gov/programs/fysb/resource/aegp-fact-sheet.

• Pregnancy Assistance Fund. Administered by the Office of Adolescent Health (OAH) at HHS and 

established under the Affordable Care Act (Section 10212), this program provides a seamless 

network of services to expectant and parenting teens, women, and families to allow them to: (1) 

Complete high school or postsecondary degrees; and (2) Gain access to health care, housing, child 

care, and other supports. The program also seeks to improve services for pregnant women who are 

victims of domestic violence, sexual violence, sexual assault, and stalking. In July of 2013, OAH 

competitively awarded 17 new grants to states and tribes for a four year period. Information is 

available at: http://www.hhs.gov/ash/oah/oah-initiatives/paf/home.html. 

Maternal, Infant, and Early Childhood Home Visiting (MIECHV)

The Affordable Care Act (Section 2951) created the MIECHV program which seeks to support families, 

including those of adolescent mothers, and improve outcomes for children through home visiting 

programs. Administered by the Maternal and Child Health Bureau at the Health Resources Services 

Administration (HRSA), the program facilitates collaboration and partnership at the federal, state, and 

community levels to improve health and development outcomes for at-risk children through evidencebased home visiting programs. Families voluntarily choose to participate in the program, which seeks to 

improve maternal and child health, child health and development, parenting skills, school readiness, 

 14 Hamilton BE, Mathews TJ, Ventura SJ. Declines in state teen birth rates by race and Latino origin. NCHS data 

brief, no 123. Hyattsville, MD: National Center for Health Statistics. 2013. Accessed August 2013 at: 

http://www.cdc.gov/nchs/products/databriefs.htm
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family economic self-sufficiency, and coordinated referrals for other community resources and supports. 

As of March 2013, awards have been made to support programs in 53 states and territories. Information 

is available at: http://mchb.hrsa.gov/programs/homevisiting/.

Childhood Obesity Demonstration Project

This demonstration project , supported by the Affordable Care Act (Section 4306), aims to address 

childhood obesity, which has both immediate and long term effects including diabetes, heart disease 

risk factors, and obesity as an adult.4 Based on 2007-2008 data, an estimated 10 percent of children 

ages 2-5 were obese and about 20 percent of children ages 6-11 were obese.15 Administered by the 

Centers for Disease Control and Prevention, the project targets children ages 2-12. The program targets 

children covered by CHIP. Information on the project is available at: 

http://www.cdc.gov/obesity/childhood/researchproject.html.

Community Health Centers

To help adolescents and adults without access to a usual source of care, the Affordable Care Act (Section 

10503) invests in Health Centers. Approximately $11 billion was appropriated over 5 years for 

operation, expansion, and construction of health centers throughout the nation. About $9.5 billion was

provided to (1) Support ongoing health center operations; (2) Create new health center sites in 

medically underserved areas; and (3) Expand preventive/ primary health care services. By the end of 

this fiscal year, approximately $5 billion in Affordable Care Act resources will have been invested in 

health centers. Information on locations of health centers is available at: 

http://www.healthcare.gov/using-insurance/low-cost-care/community-health-centers/index.html.

Because of the Affordable Care Act, more Americans will have access to affordable health insurance 

coverage. For adolescents, the Affordable Care Act expands health insurance coverage, increases access 

to comprehensive benefits, and places greater emphasis on prevention and wellness. 

Table 2: Key Provisions of the Affordable Care Act Relevant to Adolescents

Provisions In Effect

Medicaid/ CHIP

Maintenance of pre-Affordable Care Act Medicaid and CHIP 

eligibility levels for children younger than 19 

March 23, 2010 through September 30, 

2019

Expanded Medicaid eligibility to 133 percent of Federal 

Poverty Guidelines for children ages 6-18

January 1, 2014

Required Medicaid continued coverage for some current and 

former children in foster care ages 25 and younger

January 1, 2014

Private Insurance

Recommended preventive services with no deductible or copay Plan years beginning on or after 

September 23, 201016

Women’s preventive services with no deductible or co-pay August 1, 201216

Prohibition on pre-existing conditions Plan years beginning on or after 

September 23, 2010 (under 19); 

January 1, 2014 (all ages) 17

 15 Centers for Disease Control and Prevention, Data from 2007-2008 NHANES. Accessed August 2013 at: 

http://www.cdc.gov/nchs/data/hestat/obesity_child_07_08/obesity_child_07_08.htm

16 Other than Grandfathered Plans. 17 Other than grandfathered individual market policies.
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Expansion of dependent coverage (19-25) under parent’s 

health insurance

Plan years beginning on or after 

September 23, 2010

Guaranteed issue of health insurance regardless of applicant’s 

health status or other factors 

Plan years beginning on or after

January 1, 201418

Essential Health Benefits

Coverage of pediatric services, including dental and vision, to 

age 19

Beginning on or after January 1, 201419

Mental health and substance use coverage, with federal 

parity requirements 

January 1, 2014

Prohibition of lifetime limits on coverage on essential health 

benefits

Plan years beginning on or after

September 23, 2010

Prohibition of annual limits on coverage of essential health 

benefits 

Plan years beginning on or after

January 1, 201420

Health Insurance Marketplace (Exchanges)— New, 

transparent mechanism to shop for affordable coverage. Tax 

credits for eligible households below 400 percent of Federal 

Poverty Guidelines, for those not Medicaid/CHIP eligible.

January 1, 2014

 18 Other than for grandfathered plans, which may be subject to pre-ACA guaranteed issue requirements. 19 Non-grandfathered insurance plans in the individual and small group markets for plan or policy years beginning 

on or after January 1, 2014. 20 The complete prohibition on annual limits applies to all group health plans and insurance plans in the group 

health market for plan years beginning on or after January 1, 2014. Restrictions on annual limits on essential health 

benefits apply for group health plans and insurance plans in the group health market for plan years beginning on 

or after September 23, 2010.