Center&for&Adolescent&Health&&&the Law

National&Adolescent&and&Young&Adult&Health&Information&Center

November&2012

The$Supreme$Court$ACA$Decision:

What$Happens$Now for$Adolescents$and$Young$Adults?

Abigail&English,&Center&for&Adolescent&Health&&&the&Law, and&M.&Jane&Park,&NAHIC, UC&San&Francisco

INTRODUCTION

On#June#28,#2012, the#United#States#Supreme#

Court affirmed the#constitutionality#of#

critically#important#components of#the#Patient#

Protection#and#Affordable#Care#Act#of#2010#

(ACA ),#allowing#the#vast#majority#of#the#Act#to#

stand (“ACA#decision”). 1, 2, 3 In#light#of#the#2012#

election#results ,#the#ACA#is#now#more#likely#to#

be#implemented.#This#issue#brief#describes the#

implications#of#the#Supreme#Court’s#ACA#

decision#for#adole scents#and#young#adults .

The complex#web#of#majority#and#dissenting#

opinions#that#comprised#the#Supreme#Court’s#

ACA#decision has#important#implications#for#

future#health#insurance#coverage#and#health#

care#access#for#adolescents#and#young#adult s.#

Specifically,#following#the#ACA#decision,#key#

elements#of#implementation#will#include

provisions#related#to:

! the#“individual#mandate”;

! private#health#insurance;

! public#health#insurance—Medicaid#and#

the#Children’s#Health#Insurance#Program#

(CHIP);#and

! preventive#health#services.

This brief#begins#with#a#summary#of#the

current health insurance#status#of#

adolescents#and#young#adults .#It#continues#

with#a#dis cussion#of#implementation#of#the

key elements#of#the#ACA#and#what#that will#

mean#for#these#two#age#groups.#Finally,#the#

brief highlight s#implementation#choices# still#

to#be#made#by#the#federal#government#and#

the#states#that#will#affect#adolescents ’ and#

young#adults’#access#to#health#insurance#and#

health#care#services.

As#enacted#in#2010,#the#ACA#contained#

numerous#provisions#relevant#to#adolescents#

and#young#adults#that#were#scheduled#to#take#

effect#beginning#in#2010#and#culminating#in#

2014. 4 A#more#detailed#description#of#these#

provisions,#which#are#referred#to#throughout#

this#brief, is#available#here.#Additional#

resources#analyzing#the#Supreme#Court’s#

decision#and#its#implications#for#

implementation#of#the#ACA#are#included#in#the#

references in#this#issue brief.

HEALTH)INSURANCE)STATUS)OF)

ADOLESCENTS)AND)YOUNG)ADULTS

In#2011,#8 9.3%#of#adolescents#(ages#10Y17)#had#

continuous#health#insurance#coverage#for#at#

least#a#year;#for#young#adults#(ages#18Y25)#this#

figure#was#only#66.7%.#As#shown#in#Table#1,#a#

little#more#than#half#of#adolescents#and#young#

adults#are#covered#by#private#insurance.#About#

a#third#of#adolescents#have#public#insurance,#

compared#to#only 15%#of#young#adults.#Two#

federalY state#programs,#Medicaid#and#CHIP,

account#for#most#public#coverage#of#

adolescents#and#younger#children;#Medicaid#is#

the#primary#source#of#public#insurance#for#

young#adults. 5, 6

INDIVIDUAL)MANDATE

The#ACA#requires most#individuals#in#the#U.S.,#

beginning#in#2014,#to#have#health#insurance#

coverage#that#meets#certain#minimum#criteria#–

a#requirement#known#as#the#individual#

mandate.#The#Supreme#Court#upheld#this#

provision. This#means#that#the#federal#

Table&1.&Insurance&status&of&Adolescents&and&Young&Adults,&by&source&and&

duration&of&coverage,&2011

Adolescents

10L17

Young&Adults&

18L25

Insured&for&full&year&prior&to&interview

• Private&coverage 56.7% 51.5%

• Public&coverage 32.6% 15.2%

Uninsured&for&all&or&part&of&year&prior&to&

interview

• FullLyear&uninsured 5.1% 18.7%

• PartialLyear&uninsured 6.6% 14.5%

Source:(Analysis(of(2011(National(Health(Interview(Survey

Note:(Numbers(total(slightly(more(than(100%(percent(due(to(the(1A2%(of(

adolescents(and(young(adults(with(both(private(and(public(coverage.
The&Supreme&Court&ACA&Decision:&&

What&Happens&Now&for&Adolescents&and&Young&Adults?

Center&for&Adolescent&Health&&&the&Law

National&Adolescent&and&Young&Adult&Health&Information&Center

November&2012

2

government#can#impose#a#penalty#on#most#

individuals#without#health#insurance .

The#individual#mandate#applies#to#all#age#

groups,#including#adolescents#and#young#

adults#as#well#as#other#age#groups. 7 It# can#be#

satisfied#by#having#coverage#through#an#

employerYbased#plan,#Medicaid,#Medicare,#

other#public#coverage#that#meets#federal#

requirements,#or#an#individual#private#plan,#

purchased#in#the#private#market#or#through#the#

health#insurance#exchanges as#explained#in#

further#detail#below.#Most#individuals#and#

families#who#already#have health#insurance#

will#be#able#to#satisfy#the#mandate#with#the#

coverage#they#already#have.#The financial#

penalty#for#those#who#do#not#have#health#

insurance#coverage#will#be#assessed#in#

connection#with#filing#income#tax#returns.#An#

individual#whose#income#is#too#low#to#meet#

the#tax#filing#requirements#would#not#be#

subject#to#a#penalty.

For#most#adolescents#under#age#18,#their#

parents#will#be#responsible#for#ensuring#that#

they#have#the#requisite#coverage.#Adolescents#

whose#families#have#employerYbased#coverage#

will#likely#be#included#in#the#policy#if#

dependent#coverage#is#available.#Some#

adolescents#whose#parents are#uninsured#will#

be#eligible#for#Medicaid,#although#once#the#

ACA#is#implemented,#the#number#of#uninsured#

families#should#diminish#significantly.

Young#adults#age#18#and#older#are#more#likely#

to#be#responsible#for#their#own#health#

insurance.#Some#may#have#coverage#through#

their#employment#and#some#may#be#eligible#for#

Medicaid or#coverage#on#a parent’ s#plan.#For#

the#remaining#young#adults ,#th e decision#of#

whether#to#purchase#coverage#will#likely#

involve#their#perceived#need#for#insurance, as#

well#as# calculations#based#on#the#cost#of#health#

insurance#options#in#their#state,#the#amount#of#

subsidies#that#might#be#available,#and#the#

amount#of#the#penalty#they#would#incur#by#not#

having# coverage.#The#amount#of#the#penalty#

will#vary#according#to#a#formula#based#on#

household#income,#with the#amount#increasing#

over#a#three Yyear#period.#(See#Box#1)#

PRIVATE)HEALTH)INSURANCE

The#ACA#contains#numerous#provisions#

related#to#private#health#insurance#that#were#

left#intact#by#the#Supreme#Court’s#ACA#

decision and#are#important#for#adolescents#and#

young#adults .#They#include:

! s tate#health#insurance#exchanges;

! premium#tax#credits#and#costY sharing#

subsidies;

! catastrophic#coverage;#

! dependent#coverage#to#age#26;

! protection#for#preYexisting#conditions;#and#

! “Essential#Health#Bene fits”.

Health(Insurance(Exchanges

State#health#insurance#exchanges#(“the#

exchanges”)#are#a#key#feature#of#the#ACA’s#

approach#for#expanding#health#insurance#

coverage. 8, 9 States#may#choose#to#operate#their#

own#exchange,#partner#with#the#federal#

government#to#run#an#exchange,#or#allow#the#

federal#government#to#operate#an#exchange. 10

In#the exchanges,#individuals#and#small#

businesses#can#shop#for,#compare,#and#

purchase#health#insurance#coverage#beginning#

in#January#2014.#Important#functions#of#the#

exchange s inc lude#determining#eligibility#and#

enrolling#individuals#in#private#market#health#

Box$1.$ACA$Math:$What$is$the$penalty$for$not$having$

health$insurance?$

In&2014,&the&penalty&will&be&the&greater of&$95&or&1%&of&

income;&in&2015,&$325&or&2%&of&income;&and&in&2016&and&

thereafter,&$695&or&2.5%&of&income,&adjusted&for&cost&of&

living.&In&any&year,&the&penalty&cannot&exceed&the&national&

average&premium&for&the&lowest&cost&for&that&year&of&a&

“Bronze”&plan&available&through&the&exchanges.

A&young&adult&earning&$20,000&per&year&(about&174%&FPL&or&

slightly&more&than&the&equivalent&of&fullLtime&work&at&the&

federal&minimum&wage),&who&has&no&tax&deductions&or&

other&factors&affecting&taxable&income,&and&who&chooses&

not&to&have&health&insurance,&would&likely&pay&a&penalty&of&

about&$200&in&2014,&$400&in&2015,&and&$695&in&2016,&but&

the&penalty&could¬&exceed&the&national&average&premium&

for&a&Bronze&plan.

Source:(Henry(J.(Kaiser(Family(Foundation.(Focus(on(

Health(Care(Reform:(A(Guide(to(the(Supreme(Court’s(

Affordable(Care(Act(Decision.(July(2012.(Available(at:(

www.kff.org/healthreform/upload/8332.pdf.
The&Supreme&Court&ACA&Decision:&&

What&Happens&Now&for&Adolescents&and&Young&Adults?

Center&for&Adolescent&Health&&&the&Law

National&Adolescent&and&Young&Adult&Health&Information&Center

November&2012

3

plans#– such#as#a#Platinum,#Gold,#Silver,#or#

Bronze#“qualified#health#plan” – o r in#

Medicaid#or#CHIP.# Eligibility#to#enroll#in#a#

qualified#health#plan is#available#to#

individuals#who#are#either#citizens#or#

noncitizens#lawfully#present#in#the#U.S.,#are#

not#incarcerated,#and#are#residents#of#the#state.

The eligibility#and#enrollment#process#is#

supposed#to#be#seamless,#so#that#individuals#

can#fill#out#a#single#application#and#then#be#

enrolled#in#the#appropriate#plan#or#program.#

This#streamlined#process#could#be#particularly#

important#for#young#adults#obtaining#their#

own#health#insurance#for#the#first#time;#and#for#

adolescents’#families#who#are#unsure#which#

type#of#coverage#is#most appropriate#for#their#

children.

Subsidies:(Premium(Tax(Credits(and(

CostASharing(Assistance

The#exchanges#also#determine#an#individual’s#

eligibility#for#the#subsidies#established#by#the#

ACA.#These#subsidies include#both#premium#

tax#credits#and#assistance#with#costY sharing

such#as#deductibles#and#coYpayments .#

Individuals#are#eligible#for#these#subsidies#

only#if#they#are#enrolled#in#a#qualified#“Silver”#

plan and#meet#other#criteria.#

Criteria#for#the#premium#tax#credits#include#

the#source#of#insurance;#specifically,#eligibility#

is#limited#to#those#individuals eligible#for#

coverage#in#the#individual#market#– not#the#

group#market#– that#would#satisfy#the#

individual#mandate.#Thus , young#adult s who#

have access#to#a#plan through#their#

employment usually#would#not#be#eligible#for#

premium#tax#credits#through#the#exchanges .#To#

qualify#for#a#premium#tax#credit,#an#individual#

generally#must#have#household#income#

between#100%#and#400%#of#the#Federal#Poverty#

Level#(FPL). CostY sharing#subsidies#are#

available#to#those#with#incomes#between#100%#

and#250%#FPL.#(See#Box#2#for#sample#

calculation#of#subsidies .) For#a#single#person#

in#2012,#100%#FPL#is#$11,170;#250%#FPL#is#

$27,925;#and#400%#FPL#is#$44,680.

The#two#subsidies#are#structured#to#minimize#

impediments#that#would#prevent#young#adults#

from having#health#insurance#and seeking#

needed#health#care.#First,#the#premium#tax#

credits#are#payable#in#advance#so#that#

individuals#do#not#have#to#wait#until#they#file#

their# income#tax#returns to#receive#the#subsidy.#

Second,#the#costY sharing#subsidies#for#

deductibles#and#coYpayments#are#payable#

directly#to#the#health#plan,#so#that#the#outYo fY

pocket#amount#the#individual#actually#pays#is#

reduced. The#combination#of#premium#tax#

credits#and#costY sharing#assistance#may be#a#

major#factor#leading#many#lowYincome#young#

adults to#decide#to#purchase#health#insurance.

Catastrophic(Coverage

Some#young#adults#may#conclude#that#even#the#

cost#of#a#Bronze#plan,#or#a#Silver#plan#with#

subsidies,#is#too#expensive.#For#these#young#

adults,#if#they#are#under age#30,#the#ACA#

offers#the#option#of#purchasing#“Catastrophic”#

coverage,#which#may#also#be#offered#through#

the#exchanges. 11 Catastrophic#plans#will#be#

valued#at#less#than#the#Bronze#plan#and#will#

almost#certainly#have#lower#premiums.#Similar#

plans#have#been#available#in#the#commercial#

market#in#some#states#for#several#years, aimed

at#young#adults#and# sometimes#referred#to#as#

“young#invincibles” plans.#

What#makes#the#Catastrophic#plans less#

expensive#than#the#Platinum,#Gold,#Silver,#and#

Bronze#plans#are#t heir#very#high#deductibles.#

(The#deductible amount#is#to#be#determined#by#

the#tax#code;#according#to 2012#rules , it#would#

Box$2.$ACA$Math:$What$calculations$are$involved$in$choosing$a$

health$plan?$

A&young&adult&age&22&living&in&a&state&in&a&medium&cost®ion&earning&

$20,000&in&2014&dollars&(roughly&fullLtime&at&the&federal&minimum&

wage)&would&expect&the&annual&premium&cost&for&a&“Silver”&plan&to&be&

$3391.&The&anticipated&subsidy&(in&the&form&of&a&tax&credit)&would&be&

$2371,&leaving&the&individual&with&a&premium&payment&of&$1020,&

about&30%&of&the&cost&of&the&premium.&As¬ed&in&Box&1,&the&penalty&

for&this&individual&would&be&$200&in&2014.&Thus,&the&difference&

between&the&penalty&and&the&estimated&cost&of&a&Silver&plan&in&2014&

would&be&about&$820&per&year.&The&costLsharing&assistance&would&

reduce&the&overall&outLofLpocket&costs&for&this&individual&from&30%&of&

the&value&of&the&plan’s&benefits&and&services&to&13%&of&that&value.&

Source:(Henry(J.(Kaiser(Family(Foundation.(Health(Reform(Subsidy(

Calculator.(

http://healthreform.kff.org/SubsidyCalculator.aspx#incomeAgeTables

.(
The&Supreme&Court&ACA&Decision:&&

What&Happens&Now&for&Adolescents&and&Young&Adults?

Center&for&Adolescent&Health&&&the&Law

National&Adolescent&and&Young&Adult&Health&Information&Center

November&2012

4

be#$6,050 for#an#individual,#and#presumably#

would#be#higher#by#2014).#Catastrophic#plans#

must#include#coverage#for#at#least#three#

primary#care#visits#and#preventive#health#

services#that#are#not#subject#to the#deductible,#

but#any#other#benefits#included#in#the#

Essential#Health#Benefits#(described#below)

would#be#subject#to#this#high#deductible.#For

young#adults#who#are#healthy,#these#plans may#

seem#appealing#due#to#their#low#premium#cost

and#the#availability#of#some#primary#care#and#

preventive#services#without#additional#outYo fY

pocket#costs .#However,#the#very#high#

deductible#for#these#plans#means#that#any#

young#adult#who#has#an#accident,#who#

contracts#a#serious#illness,#or#whose#health#

status#changes#for#the#worse may#quickly#

confront#prohibitive#medical#costs#in#

circumstances#where#the#need#for#care#is#

critical.

Dependent(Coverage(to(Age(26

Effective#September#2010,#the#ACA#required#

most#health#plans#to#allow#individuals#to#

remain#on#a#parent’s#policy#up#to#age#26. 12 This#

coverage#must#be#offered#regardless#of#the#

young#person’s#age,#financial#independence#or#

dependent#status,#marriage,#or#educational#

enrollment.#The#premiums#charged#and#the

benefits#covered#must#be#the#same#as#for#

younger#children#under#the#same#policy.

In#June#2012,#the#U.S.#Department#of#Health#&#

Human#Services#(HHS)#announced#that#3.1#

million#more#young#adults#ages#19#to#25#had#

gained#health#insurance b y the#end#of#2011

than#would#have#been#covered#without#the#

ACA. 13 Research#by#HHS#also#shows#that#the#

ACA’s#expansion#of#dependent#coverage#

benefits#young#adults#of#all#races#and#

ethnicities. 14 This#provision will#continue#to#

reach#a#significant#proportion#of#previously#

uninsured#young#adults.#It#is#not#known#at#

this#time#how#many#young#people#will#remain#

on#a#parent’s#policy#rather#than#purchase an#

individual#policy#once#the#exchanges#are#

operating#in#2014,#but#for#now#the#dependent#

coverage#requirement#has#had#a#major#impac t

on#health#insurance#coverage#for#young#adults .#

Protection(for(PreAexisting(Conditions

The#ACA#eliminates#the#longY standing#

practices#of#health#insurers#that#make#it#

difficult#for#individuals#with#preYexisting

conditions to#obtain#coverage#in#a#timely#

manner or#even#to#obtain#coverage#at#all.#

Effective#in#2010,#the#ACA#prohibited#health#

plans#from#imposing#preYexisting#condition#

exclusions#for#children,#including#adolescents#

who#are#minors.#A#similar#provision#will#apply#

to#all#age#groups#beginning#in#2014:#health#

plans#will#no#longer#be#able#to#refuse#to#issue#

a#policy#to#individuals#with#preYexisting#

conditions#or#impose#a#waiting#period#for#

coverage#of#such#conditions.#Thus , when#this#

provision#is#implemented in#2014,#millions#of

young#adults#with#chronic#diseases#or#pre Y

existing#conditions#will#no#longer#be#

prevented#from#obtaining#health#insurance#as#a#

result#of#their#health#status and#will#join#the#

millions#of#adolescents#under#age#18#who#have#

been#protected#in#this#way#since#2010.#Federal#

estimates#of#the#percentage#of#children#and#

young#adults#who#will#be#affected#range#from#

5%#to#24%#of#children#under#age#18#and#9%#to

35%#of#young#adults#ages#18Y2 4. 15

Essential(Health(Benefits

Plans#that#are#offered#through#the#exchanges#

must#cover#a#set#of#comprehensive#benefits,#

including#at#least the 10#“Essential#Health#

Benefits”#as#specified b y the#ACA. 16, 17 (See#Box#

3 ) The#ACA#lists broad#categories#of#services#

that#comprise#Essential#Health#Benefits (EHBs),

but#leaves it#to#HHS#to#define#them#further.#

HHS#has#delegated#significant#flexibility#to#the#

states#to#determine#what#constitutes#Essential#

Health#Benefits#within#the#10#categories . 18, 19

HHS#set#a#“soft#target” date#of#October#1,#2012

for#states#to#determine#their#Essential#Health#

Box)3:)Ten)Essential)Health)Benefits

1. ambulatory&patient&services;&

2. emergency&services;&

3. hospitalization;&

4. maternity&and&newborn&care;&

5. mental&health&and&substance&

abuse&disorder&services,&

including&behavioral&health&

treatment;

6. prescription&drugs;

7. rehabilitative&and&habilitative&

services&and&devices;

8. laboratory&services;

9. preventive&and&wellness&and&

chronic&disease&management;&

and

10. pediatric&services,&including&

oral&and&vision&care.
The&Supreme&Court&ACA&Decision:&&

What&Happens&Now&for&Adolescents&and&Young&Adults?

Center&for&Adolescent&Health&&&the&Law

National&Adolescent&and&Young&Adult&Health&Information&Center

November&2012

5

Benefits package by#selecting a#benchmark#

plan#to#base#it#on. 20 About#a#third#of#states had#

not#identified#a#package#by#that#targeted#

timeline . 21 At#the#time#of#this#writing,#it#is#

unclear#precisely#how#the#EHB#packages#will#

vary#by#state. 22

The#inclusion#of#mental#health#and#substance#

abuse#disorder#services#is#essential#for#some#

adolescents#and#young#adults. 23 The#adolescent#

and#young#adult#years#are#critical#for#

identifying#and#treating#mental#health#and#

substance#use#problems ,#as#symptoms#of#

nearly#half#of#lifetime#diagnosable#problems#

appear#by#age#14#and#symptoms#of#nearly#three#

quarters#of#these#problems#begin#by#age#24. 24

Among#young#adults#(ages#18Y25)#in#2010,#

15.8%#had#a#substance#use#disorder#and#8.2%#

had#a#major#depressive#episode#(a#widely#

measured#disorder)#in#the#past#year;#for#

adolescents,#these#figures#were#4.6%#and#8. 0%,#

respectively. 25 Another#welcome#addition#is#the#

inclusion#of#dental#and#vision#care#for#children.#

However,#a#serious#omission#is#the#lack#of#any#

requirement#for#dental#or#vision#care#for#

adults.#Young#adult s#face#tremendous#

problems#in#access#to#dental# care.#Among#18Y

to#2 5YyearYolds ,#42%#did#not#have#a#pastYyear

dental visit#and#17%#had#unmet#dental#needs#

in#the#past#year;#for#uninsured#young#adults,#

these#figures#are#much#higher:#7 6%#and#37%,#

respectively. 26

PUBLIC)HEALTH)INSURANCE: MEDICAID)

AND)CHIP

In#the#original#ACA#legislation,#the#“Medicaid#

expansion,”#described#below,#was#a#major#

vehicle#for#covering#the#uninsured,#along#with#

the#individual#mandate#and#the# state#health#

insurance#exchanges. The#ACA#al so#included#

other provisions related#to#Medicaid#and#CHIP.

The(Supreme(Court’s(Ruling(on(

Medicaid

The#Supreme#Court’s#ACA#decision#with#

respect#to#Medicaid#was#complex. Under#the#

ACA#statute,#a#state#that#did#not#implement#

the#Medicaid expansion#would#have#been#

penalized#by#losing# all federal#Medicaid#

support;#that#is,#a#nonY compliant#state#would#

lose#not#just#the#federal#support#for#the#

expansion,#but#all#federal#funds#that#support#

the#state’s#Medicaid#program#in#its#entirety.

The#Supreme#Court#held#that#this#enforcement#

mechanism#was#unconstitutional.#However,#it#

allowed#the provision#expanding#Medicaid#to#

individuals#up#to#133%#FPL#to#stand,#along#

with#the#increased#federal#support#for#that#

expansion. 27, 28, 29, 30, 31

Thus , as#a#result#of#the#ACA#decision,#the#

Medicaid#expansion#is ,#in#effect, optional#for#

the#states#to#implement. 32, 33 All#other#Medicaid#

and#CHIP#related#provisions#of#the#ACA#

remain#fully#effective,#including several#more#

fully#discussed#below:#

! maintenance#of#preYACA#Medicaid#and#

CHIP eligibility levels (“maintenance#of#

effort”);

! mandatory#increase#in#the#eligibility#level#

for#children#ages#6Y18;

! requirement#for continued Medicaid#

coverage#up#to#age#26#for#former#foster#

youth;

! option#for#states#to#establish#health#homes#

for#individuals#with#chronic#conditions;#

and

! option#for#states#to#establish#a#Basic#Health#

Program.

Medicaid(Expansion

As#a result#of#the#ACA#decision, states ,#in#

effect, have#the#option#of#adopting#a#new#

eligibility#group#for#their#Medicaid#programs#

that#includes#all#citizens and longYterm#legal#

residents#in#the#U.S.#who#are#under#age#65,#are#

not#pregnant,#do#not#have#disabilities , and#

whose#incomes#are#below#133%#FPL#(or#138%#if#

income#dis regards#are#included). Medicaid#

already#covers#those#who#are#pregnant#and/or#

have#disabilities#at#least#up#to#this#level#and#

those#over#age#65#are#eligible#for#Medicare.

The#Medicaid#expansion#will#reach#both#

parents#and#childless#adults,#whose#access#to#

Medicaid#in#most#states#is#extremely#limited#or#

nonexistent. As#of#January#2012, working#

parents#were#covered by#Medicaid in#17#states#

only#at#income#levels#below 50%#FPL,#in#16#

states#at#income#levels#from#50Y99%#FPL,#and#

in#only#18#states#and#DC#at#100%#FPL#or#a#
The&Supreme&Court&ACA&Decision:&&

What&Happens&Now&for&Adolescents&and&Young&Adults?

Center&for&Adolescent&Health&&&the&Law

National&Adolescent&and&Young&Adult&Health&Information&Center

November&2012

6

higher#level.#Also#in#January#2012,#childless#

nonYdisabled#adults#in#26#states#had#no#access#

at#all#to#Medicaid#coverage. 34, 35

Young&Adults

It#is#widely#agreed#that#young#adults#will#be#

among#the#leading#beneficiaries#of#the#

Medicaid#expansion.#For#example,#one#recent#

estimate,#issued#after#the#ACA#decision,#

suggests#that#of#the#15#million#newly#eligible#

(taking#into#consideration#that all#states#may#

not#implement#the#expansion)#about#half#(7.8#

million)#will#be#unde r#age#35. 36

Without#the#expansion,#many#young#adults#

will#continue#to#face#the#extremely#low#

Medicaid#eligibility#levels#that#were#in#place#

in#their#states#prior#to#the#ACA.#In#these#

circumstances,#their#incomes#might be#too#high#

to#qualify#for#Medicaid#under#their#state’s#old#

Medicaid#eligibility#levels , but#too#low#to#meet#

the#lowYend#threshold#of#100%#FPL#for#

enrolling#in#a#subsidized#plan#through#the#

exchanges .#If#this#were#to#occur,#one#of#the#

results#of#the#Supreme#Court’s#ACA#decision#

could#be#to#leave#uninsured#one#of#the#most#

vulnerable#groups#the#ACA#was#designed#to#

help.

Certain#vulnerable#populations#are#especially#

likely#to#be#among#those#who#will#benefit#from#

the#Medicaid#expansion.#These#include,#for#

example,#homeless#individuals and#individuals#

who#have#been#involved#with#the#criminal#

justice#system,#among#whom#young adults#are#

heavily#represented. 37, 38 Each#of#these#groups#is#

at#high#risk#for#having#multiple#serious#health#

problems,#including#mental#health#and#

substance#abuse disorders .#They#also#

frequently#have#encountered#severe#

difficulties#accessing#needed#medical#care.#

States#that#have#expanded#Medicaid#in#the#past#

to#childless#adults#have#experienced#

significant#enrollment#by#these#groups.##A#

study#of#significant#expansions#of#Medicaid#in#

three#states#– Arizona,#Maine,#and#New#York#–

found#numerous#benefits resulting#from#the#

expansions. 39, 40 These#benefits#included

improved#access#to#care#and#selfYreported#

health,#as#well as#decreased#mortality.#Thus ,

the#decision#by#states#of#whether to#expand#

Medicaid#or#not#is#likely#to#have#significant#

implications#for#the#health#of#vulnerable#lowY

income#young#adults.

Benefits&for&Newly&Eligible&

It#will#be#challenging#to#ensure#that#adolescent#

and#young#adult#Medicaid#beneficiaries#with#

complex#medical#needs#not#only#have#coverage,

but#actually#receive#needed#care – this#will#be#

true#for#both#the#newly#eligible#and#those#who

have#been#eligible#under#prior#law.#The#ACA#

requires#that#newly#eligible#adult#Medicaid#

beneficiaries#have#access#to#at#least#the#

minimum#Essential#Health#Benefits,#but#the#

specific#scope#of#these#benefits,#yet#to#be#

determined#for#each#state , will#affect young#

adults’#ability#to#obtain#needed#care.

Costs&of&No&Medicaid&Expansion

Apart#from#the#direct#gains#for#the#newly#

eligible#beneficiaries#themselves,#there#are#

many#reasons#for#states#to#choose#to#

implement#the#expansion. 41, 42 Over#the#first#

nine#years#of#the#expansion,#the#federal#

government#will#bear#93%#of#the#cost#– 100%#

for#the#first#three#years#and#percentages#

dec lining#to#90%#thereafter. 43, 44 If#a#state#

foregoes#those#funds#to#save#its#share#of#the#

expansion#costs,#the#state#may#incur#other#

costs#when#individuals#who#do#not#gain#

Medicaid#coverage#turn#to#emergency#rooms#

and#other#local#facilities#for#care.#Many#of#

those#individuals#will#be#young#adults,#who#

will#continue#to#suffer,#as#they#have#in#the#

past,#from#the#obstacles#that#prevent#the#

uninsured#from#seeking#care#or#impel#them#to#

incur#substantial#burdens#of medical#debt#for#

essential#services .

Maintenance(of(Effort

The#ACA# contains important#“maintenance#of#

effort”#requirement s .#Until#at#least#2014,#states#

are required#to#maintain#the#Medicaid#

eligibility#levels#that#were#in#place#when#the#

ACA#was#enacted.#For#adults,#the#Medicaid#

maintenance#of#effort provision#will no#longer#

apply#in#2014,#once#the state#health#insurance#

exchanges#are#operational.#For#children and#

adolescents#up#to#age#18,#the#maintenance#of#

effort#provisions#for#Medicaid#and#CHIP#

continue#until#2019.#Either#rolling#back#
The&Supreme&Court&ACA&Decision:&&

What&Happens&Now&for&Adolescents&and&Young&Adults?

Center&for&Adolescent&Health&&&the&Law

National&Adolescent&and&Young&Adult&Health&Information&Center

November&2012

7

eligibility#levels#or#instituting#more#

burdensome#enrollment#procedures#would#

result#in#fewer#adolescents#and#young#adults#

being#able#to#qualify#for#Medicaid and#CHIP.#

Eligibility(Increase(for(Children(and(

Adolescents

A#provision#of#the#ACA,#which#is#separate#

from#the#Medicaid#expansion and#thus#is#intact#

after#the#Supreme#Court’s#decision,#requires#

states#to#raise#the#Medicaid#eligibility#

threshold#for#children#ages#6Y18#to#133%#FPL#

effective#in#2014.#The#minimum#eligibility#

threshold for#this#age#group#was#previously#

set#at#100%#FPL,#so#that#states#were#required#

to#offer#coverage#at#least#up#to#that#level. 45

Although#at#least#10#states#had#already#

adopted#m ore#generous#levels#higher#than#

133%#FPL#by#2012,#adolescents#in#most#states#

will#benefit#from#this#higher#eligibility#

threshold. Currently,#these#eligibility#levels#

vary#widely#among#the#states#for#children#ages#

6Y19#– f rom#a#low#of#100%#FPL#in#a#large

majority#of#states#to#a high#of#275%#FPL#in#one#

state. 46 Although# some#adoles cents#in#a#state#

where#eligibility#currently#exceeds#133%#FPL#

will#lose#Medicaid#eligibility#when#

maintenance#of#effort#ends for#children#and#

adolescents#in#2019,#they should#be#able#to#

receive#subsidized coverage#through#the#

exchanges .#However,#an#important question#

remains#about#whether#the#benefit#package#–

which#will#be#whatever#their#state#adopts#as#

its#Essential#Health#Benefits#– will#be#as#broad#

as#the#package#available#from#Medicaid.#

Coverage(to(Age(26(for(Former(Foster(

Youth

Another#important#provision#of#the#ACA#

requires#states ,#beginning#in#2014, to#continue#

Medicaid#coverage#for#youth#aging#out#of#

foster#care#until#they#reach#age#26. 47 These#

youth#are#among#the#most#vulnerable,#both#

because#they#are#at#risk#for#multiple#health#

problems,#and#because#they#have#extreme#

difficulty#securing#health#insurance#coverage.#

This#ACA#provision#provides#a#safety#net for#

these#young#people,#who#do#not#have#families#

to#support#them,#that#is comparable#to#the#one#

allowing#other#young#adults#to#remain#covered#

as#a#dependent#on#a#parent’s#health#insurance

plan#to#age#26.#Even#with#this#coverage#

requirement#in#place,#numerous#questions

remain about#how#to#implement#it#in#ways#that#

will#ensure#i t reaches#the#eligible#former#foster#

youth.

Health(Homes

One#potential#complement#to#the#Essential#

Health#Benefits#for#Medicaid#eligible young#

people#is#the#ACA’s#provision#giving#states#a#

new#option#to#create#“Health#Homes.” 48 These#

Health#Homes#offer#the#possibility#of#

providing#coordinated#care#to#Medicaid#

beneficiaries#who#have#one#or#more#chronic#

conditions , such#as#mental#health#or#substance#

abuse#disorders,#asthma,#diabetes,#or#severe#

obesity.#The#list#of#services#is#broad#and#

includes#care#coordination,#support,#and#

referral#services,#which#can#be#provided#by#a#

range#of#designated#providers#or#various#

health#teams.#States#receive#a#90%#federal#

match#for#the#specific#Health#Home#services#

( separate#from funding for the#underlying#

Medicaid#services)#provided#to#an#individual#

for#up#to#two#years#(or#eight#quarters).#This#

option#holds#promise#for#increasing#access#to#

coordinated care for#adolescent#and#young#

adult#Medicaid#beneficiaries#who#have#

complex#medical#ne eds#or#chronic#conditions.

As#of#August#2012,#20#states#had#expressed#

interest#in#this#option#and#six#had#received#

approval#to implement#it.

Basic(Health(Program

The#ACA#made#an#additional#option#available#

to#states#to#establish#a#Basic#Health#Program#

(BHP),#an#additional#mechanism for#insurance#

c overage that#states#can#offer#using#federal#tax#

subsidy#dollars . 49, 50 Not#technically#part#of#

Medicaid,#the#BHP#option#is#intended#as#

another#way#for#states#to#increase#continuity#

of# coverage#and# care#for#low#income#

populations#by#bridging#potential#eligibility#

gaps#between#Medicaid#and#the#exchanges .#In#

states#choosing#to#establish#a#BHP,#eligible#

individuals#would#include#primarily#those#

whose#incomes#are#between#133%#and#200%#

FPL;#lawful#immigrants#with#incomes#up#to#

200%#FPL,#including#those#with#incomes#lower#

than#133%#FPL, would#also#be#eligible.#The#

benefits#would#have#to#be#at#least#equal#to#the#
The&Supreme&Court&ACA&Decision:&&

What&Happens&Now&for&Adolescents&and&Young&Adults?

Center&for&Adolescent&Health&&&the&Law

National&Adolescent&and&Young&Adult&Health&Information&Center

November&2012

8

Essential#Health#Benefits#package#in#the#state.#

Individuals#eligible#for#the#BHP#would#not#be#

eligible#for#subsidies#through#the#exchanges ,#

but#their#premiums#and#other#costY sharing#

could#not#be#higher#than#they#would#be#

through#the#exchanges .#It#is#unclear#how#many#

states#will#choose#this#option#and#many#

implementation#details#are#yet#to#be#

determined,#but#in#states#that#establish#a#BHP,#

many#adolescents#and#young#adults#would#be#

part#of the#eligible#population.

PREVENTIVE)HEALTH)SERVICES

The#Supreme#Court#decision#left#intact#all#of#

the#ACA’ s provisions to#increase#access#to#and#

use of#preventive#services in#both#private#and#

public#insurance.#These#provisions will#be,#or#

already#have#been, beneficial#for#adolescents#

and#young#adults.

Of#particular#importance#is#the#requirement#

that#most#private#health#insurance#plans# –

including#both#employerYbased#and#individual#

market#plans#– cover#a#specified#set#of#

preventive services#without#costY sharing.

These services#include#the#evidenceYbased#

screening#and#counseling#services#rated#highly#

by#the#U.S.#Preventive#Services#Task#Force;

immunizations#recommended#by#the#Advisory#

Committee#on Immunization#Practices;#the#

Bright!Futures pediatric#guidelines; and#the#

services#included#in#the#Women’s#Preventive#

Health#Services#Guidelines. 51 These#preventive#

services must also be#part#of#the#Essential#

Health#Benefits. The#requirement#for#noY cost#

coverage#of#most#of#these#preventive# services#

became#effective#in#2010;#the#addition#of#

services#specified#in#the#Women’s#Preventive#

Services#Guidelines#took#effect#in#August#2012.#

HHS#estimated#in#February#2012#that#as#a#

result#of#this#requirement,#54#million#

individuals#had#received#expanded#coverage#of#

at#least#some#preventive#services. 52

Several#of#the#preventive#services#that#must#be#

covered without#cost#sharing#for all#adults#

includes several#that#are#very#important#for#

young#adults : immunizations;#alcohol#misuse#

screening#and#counseling;#tobacco#use#

screening#and#cessation#interventions;#

depression#screening;#Type#2#Diabetes#

screening;#diet#counseling#for#adults#at#higher#

risk#for#chronic#disease; obesity#screening#and#

counseling;#HIV#screening;#STI#prevention#

counseling;#and#syphilis#sc reening.#Some#of#

these#services#are#specified#only#for#

individuals#at#increased#risk.#Most#young#

adults will#likely#benefit#from#noY cost#access#

to#these#preventive#services.

In#accordance#with the#Women’s#Preventive#

Services#Guidelines, 53 private#plans#mus t#offer#

additional#services#to#women#without#costY

sharing,#as#well#as#the# services#that#must#be#

available#to#all#adults . 54, 55, 56, 57 A#few#of#these#

additional# services#that#are#of#particular#

importance#for#female#adolescents#and#young#

adults#include: contraception;#domestic#and#

interpersonal#violence#screening#and#

counseling; and#wellYwoman#visits#to#obtain#

recommended#preventive services .#Most female#

adolescents#and#young#adults#will#likely#

benefit#from#noY cost#access#to#these#preventive#

services.#In#particular,#the#inc lusion#of#the#full#

range#of#FDAYapproved#contraceptive#methods#

is#without#question#beneficial#for#adolescents#

and#young#adults.

FUTURE)POLICY)CHOICES

The#federal#government#and#states#face#major#

policy#choices#as#implementation#of#the#ACA#

moves#forward#in#the#wake#of#the#Supreme#

Court’s#decision and#the#2012#election.#

Opponents#of#the#ACA#will#continue#to#

challenge#the#entire#ACA#or#key#parts#of#it,#

and#some#states#will#resist#implementation#of#

specific#parts#of#the#law.#HHS#and#other#

federal#agencies#will#continue#to#issue#and#

update#regulations#and#guidance with#respect#

to#significant#provisions#of#the#ACA.#Between#

now#and#2014,#particularly#important#choices#

must#be#made#by#the#states.#One#major#

decision#for#each#state is#whether to#operate#

its#own#health#insurance exchange ,#partner#

with#the#federal#government#to#run#the#

exchange,#or#leave#it#entirely#to#the#federal#

government#to#do#so.#Another#key#choice#for#

each#state i s whether (and#when) to#implement#

the#Medicaid#expansion. HHS#has#offered#

flexibility#to#the#states#with#some#of#the#

deadlines#associated#with#these#choices and#

with#other#requirements ,#so#some#aspects#of#
The&Supreme&Court&ACA&Decision:&&

What&Happens&Now&for&Adolescents&and&Young&Adults?

Center&for&Adolescent&Health&&&the&Law

National&Adolescent&and&Young&Adult&Health&Information&Center

November&2012

9

ACA#implementation#may#continue#to#be#a#

moving#target.

As#ACA#implementation#moves#forward, key#

questions#to#monitor#in#order#to#determine#

how#adolescents#and#young#adults#will#be#

affected#include:

! What#specific#content#is#included#in#the#

Essential#Health#Benefits#package#in#each#

state?

! Which#preventive#services#are#included#in#

each#state’s#Essential#Health#Benefits#

package?

! H as#the#exchange#in#each#state#established#

a#seamless#process#for#applying#for#

individual#coverage#and#being#approved#

for#the#appropriate#plan?

! Is#there#an#effective#process#for#

determining#eligibility#for#premium#tax#

credits#and#costY sharing#subsidies?

! Has#each#state#opted#to#implement#the#

Medicaid#expansion?

! In#states#that#do#not#implement#the#

Medicaid#expansion#are#some#young#adults#

left#uninsured#due#to#a#gap#between#the#

eligibility#level#for#Medicaid#and#for#the#

exchange?

! Has#each#state#increased#its#Medicaid#

eligibility#level#up#to#133%#FPL#for#

children#and#adolescents ages#6Y1 8?

! Has#each#state#maintained#its#Medicaid#and#

CHIP#eligibility#levels#for#children#and#

adolescents#until#2019?

! Has#each#state#extended#Medicaid#coverage#

for#former#foster#youth#to#age#26?

CONCLUSION)

The#Supreme#Court’s#ACA#decision#and#the#

recent#election#h av e given#a#green#light#to#

continued#implementation#of#the#ACA#–

signal s that#are welcome#to#those#concerned#

about#the#health#and#health#care#access#of#

adolescents#and#young#adults.#Many#complex#

questions about#eligibility,#scope#of#benefits,#

subsidies,#and#access#to#care#for#these#age#

groups remain#unanswered.#Many#important#

dec isions#must#still be#made#by#the#federal#

government#and#the#states#that#will#have#a#

significant#impact on#adolescents#and#young#

adults#– especially#decisions#about#whether#to#

implement#the#Medicaid#expansion#and#which#

specific#benefits#to#include#in#the#Essential#

Health#Benefits#package .#At#this#time, however,#

all#the#indications#are#that#the#Supreme#

Court’s#decision#will#allow#that#the#ACA#to#be#

implemented#in#ways#that#will#benefit#millions#

of#young#people.
The&Supreme&Court&ACA&Decision:&&

What&Happens&Now&for&Adolescents&and&Young&Adults?

Center&for&Adolescent&Health&&&the&Law

National&Adolescent&and&Young&Adult&Health&Information&Center

November&2012

10

Center$for$Adolescent$Health$&$the$Law

PO#Box#3795

Chapel#Hill,#NC#27515Y3795

ph.#919.968.8850

eYmail:#info@cahl.org

http://www.cahl.org

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#nonYprofit,#

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#94143Y0503

ph.#415.502.4856

f.#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#healthY

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,#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.

Past$Issue Briefs$in$This$Series

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.

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.

Acknowledgments

The#authors#gratefully#acknowledge#the#

contributions#of#their#colleagues#at#NAHIC,#

including#Claire#D.#Brindis,#Charles#E.#Irwin,#Jr.,#and#

John#Urquhart#for#their#careful#review#of#this#brief#

and#to#Sally#Adams#for#providing#analytic#assistance.
The&Supreme&Court&ACA&Decision:&&

What&Happens&Now&for&Adolescents&and&Young&Adults?

Center&for&Adolescent&Health&&&the&Law

National&Adolescent&and&Young&Adult&Health&Information&Center

November&2012

11

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#(U45MC00002#&#U45MC00023).#

Additional#support#was#provided#by individual#

donors#to#the#Center#for#Adolescent#Health#&#the#

Law,#the#Brush#Foundation,#and#the#Theodore#Cross#

Family#Charitable#Foundation.

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