implementing the ACA:
How Much Will it Help Vulnerable Adolescents & Young Adults?

Hometess YOUTH
Highlights
Homeless youth are among those most disconnected
from social and adult support and thus are among the
most vulnerable young people. The actual size of the
homeless population is unknown. However, there is little
doubt that many thousands of youth are homeless for
either short or long periods of time; some of them are
still minors, others are young adults. These young
people experience very high rates of serious health
problems and great difficulty accessing needed health
care. Although the ACA theoretically could improve their
health insurance coverage and access to care, many
challenges will exist to make the promise a reality,
particularly in states that do not expand Medicaid.

Demographics

The total number of adolescents and young adults who are
homeless in the United States is difficult to estimate, and
existing estimates vary widely. Whereas the foster care and
juvenile justice systems are structured systems and better
suited to accounting for the populations they serve,
homelessness is unique in that its population consists of
transient individuals who are underserved, and are not found
or identified within any single system.

Unaccompanied Homeless Youth Under the Age of 18*

Category Percent | Estimated
Number
of Youth
‘Temporarily Disconnected 86% 327,000
Unstably Connected 8% 29,000
Chronically Disconnected 6% 24,000
Total 100% 380,000

‘Adapted from “An Emerging Framework for Ending
Unaccompanied Youth Homelessness.””” * *Note: no date
specified for year of estimates, but based on a 2011 study.

One estimate suggests that there are nearly 1.7 million
unaccompanied homeless youth under age 18, with
approximately 380,000 of these remaining homeless for more
than one week, and about 130,000 for more than one month,
with the remainder returning home quickly.” These homeless
youth include those who have run away from home
(“runaway youth”) as well as those who have been forced out.
Additional adolescents are homeless as part of a family, but
not counted here. The number of homeless young adults ages
18-24 is even more difficult to estimate, and reliable estimates
are not available. These young people share many

characteristics and health care needs with their younger
counterparts.” One 2013 report identified more than 61,000
homeless young, adults ages 18-24 who were either single or
parents of at least one child?

Of note are the different minority populations among the
homeless, and the specific challenges they face. A 23-city
survey estimated that 42% of the general homeless population
is African American, 39% is white, 13% is Hispanic, 4% is
Native-American, and 2% is Asian.*! Another important
minority population is LGBT y.
and transgender persons. Studies estimate that nearly 40% of
homeless youth are LGBT. *

bian; gay; bisex

Unaccompanied Homeless Single Young Adults Ages

18-24"
Category Percent Estimated Number
lof Young Adults
Transitional 81% 122,000
Episodic 9% 13,000
Chronic 10% 15,000
Total 100% 150,000

“Adapted From “An Emerging Framework for Ending
Unaccompanied Youth Homelessness.” ***Note: no date
specified for year of estimates, but based on a 2011 study.

Substantial variations exist among those who remain homeless
for more than one week: some are “low-risk” and “transient”
youth who retain relationships with their families; others are
“high-risk” youth who have highly unstable or nonexistent
family ties.” Factors contributing to homelessness among
adolescents include sexual orientation other than heterosexual
and a history of foster care placement and school expulsion. A
major longitudinal study found that by age 19, 13.8% of youth
reported ever being homeless after leaving foster care, and by
age 23-24, as many as 36.5% of former foster youth have
reported being homeless or “couch surfing” after leaving foster
care. 65

Health Status

Homeless and runaway youth generally lack primary health
care and may have increased health problems because of
factors that influenced their being homeless as well as the
increased risk and exposure that result from living on the
street.” Consequently they have extensive health care needs,
which are insufficiently met.°s.°” The health problems they
experience are similar to those affecting youth in foster care
and juvenile justice settings. These problems are often
exacerbated by their living conditions, with exposure to the
elements and limited sanitation. Areas of particular concern for

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National Adolescent and Young Adult Health information Center
January 2014


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How Much Will it Help Vulnerable Adolescents & Young Adults?

10

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1

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ASPE, U.S, Dep’t Health & Human Services. The Affordable Care 11. Rosenbach M. Children in Foster Care: Challenges in Meeting,
Act: Coverage Implications and Issues for Immigrant Families. Their Health Care Needs Through Medicaid. Princeton, NJ:
April 2012 Mathematica Policy Research Inc., 2001. Policy brief:
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mi. report: http://aspe.hhs.gov/hsp/fostercé
Children’s Bureau, Admin: for Children & Families, US Dep't healthoo/ehans.hemdi,
Heaith & Human Services. AFCARS Report No. 20. Preliminary 12. English A, Park MJ. The Supreme Court ACA Decision: What
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Dep’t Health & Human Services, 2013. NC: Center for Adolescent Health & the Law; and San Francisco,
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Implementation Centers Can Help States and Tribes. n.d. for Children and Families, Artiga S, Stephens J, Kaiser
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mplementing%20Fostering%20Connections%20Act%20Fact%20 Pressure: Annual Findings of a 50-State Survey of Eligibility,
Sheet%20- Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and
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, - ° p://www.kfforg/ 1/8272.cfm.
Committee on Early Childhood. Policy Statement: Health care of http://www J ong/medicald/8272.cim,
youth aging out of foster care. Pediatrics 2012;130;1170-1174. 14, Courtney ME, Dworsky A, Lee JS, Raap M, Midwest evaluation
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I fpeds.2012-2603. ages 23 and 24. Chicago, IL: Chapin Hall at the University of

; Chicago, 2010.
Hansen RL, Mawjee FL, Barton K, Metcalf MB, & Joye NR. http://www. chapinhall.org/sites/default/files/Midwest_Study
Comparing the health status of low-income children in and out Age. 23. 24.pdt
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AAP Committee on Early Childhood, Adootio ; 15. English A, Morreale MC, Larsen J. Access to health care for
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Afpeds.2012-2603. Health & the Law. Health Care for Adolescents and Young
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aoolcatn Ne nee nanan vee National Findings 2006. http://www. cahl.org/health-care-for-adolescents-and-
‘ockville, MD: US Dep't Hea juman Services, 2005. voduite leavinefocten
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17. tehmann 8, Guyer J, Georgetown Center for Children and

Halfon N, Mendonca A, & Berkowitz G. (1995). Health status of Families, Lewandowski K, New England Alliance for Children’s
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Center for Adolescent Health & the Law
National Adolescent and Young Adult Health Information Center
January 2014


Implementing the ACA:
How Much Will it Help Vulnerable Adolescents & Young Adults?

COMMON THEMES AND MAJOR CHALLENGES
Review of the health status, health care access, and health
insurance coverage of youth in and aging out of foster care,
youth involved in the juvenile and criminal justice systems,
and homeless youth identifies numerous common themes
among the three populations, both pre- and post-ACA
implementation. It also serves as a stark illustration that many
important challenges must be overcome to ensure that as many
of these vulnerable young people as possible have health
insurance coverage and improved health care access as the
ACA is implemented.

Common Themes

‘The demographic characteristics, health status, health care
access, and health insurance coverage of the three vulnerable
groups of young people discussed in this issue brief are
characterized by many common themes. Several of the most
salient are:

® Significant overlap and intersection among ihe three groups.
Many youth become homeless or are arrested after exiting
foster care. Many foster youth are at risk for being arrested
as juveniles. 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
center. 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 concerns of adolescents
and young adults, but 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, substantial proportions of
young people in these vulnerable groups are either
uninsured at high rates, sometimes approaching 50%, or
are at high risk for losing insurance. All are more likely to
secure health insurance coverage through Medicaid than
private health insurance.

* Disconnection from familial, adult, and social support, Many of
the vulnerable youth in all three groups, especially those
who are homeless, 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.

Major Challenges

Although numerous challenges impede access to health care
and health insurance coverage for youth exiting foster care,
youth involved in the juvenile or criminal justice system, and
homeless youth, two areas of challenge are particularly critical:
Medicaid eligibility and expansion; and outreach and
enrollment procedures.

Medicaid Eligibility and Expansion

As originally enacted, the ACA would have required all states
to expand Medicaid coverage for all individuals under age 65
who are citizens or long term legal residents, are not pregnant
or disabled, and whose incomes are below 133% FPL. In June
2012, the Supreme Court decided that states were not required
to expand Medicaid in this way, but have the option of doing
so.” As of December 11, 2013, 25 states and the District of
Columbia had decided to implement the option in 2014, and 25
states were not moving forward at this time, although two of
those are seeking to implement the option after 2014,”

‘The implications for vulnerable groups of young people in
states that choose not to implement the ACA Medicaid
expansion will be severe. Among the states that are not
expanding Medicaid, all but one do not offer any Medicaid
coverage to single adults unless they are pregnant, parents of
dependent children, or have a disability, with the exception of
some extremely limited coverage through a waiver in a small
handful of states.” 74 Even young adults who are parents of
dependent children do not fare well in the states not
expanding Medicaid: the median income eligibility level for
parents of dependent children is 47% FPL (e.g., less than
$10,000 per year in a family of three).”*Comparison of the
states that have decided to expand Medicaid with those that
have not indicates that states not moving forward with
expansion have more limited Medicaid eligibility than those
moving forward, leaving large coverage gaps that will affect
millions of individuals who are disproportionately people of
color75.76

The failure of states to expand Medicaid eligibility has
seriously adverse implications for young adults involved in the
criminal justice system and for homeless young adults. These

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


implementing the ACA:
How Much Will it Help Vulnerable Adolescents & Young Adults?

homeless youth include physical and sexual abuse and
exploitation, sexual activity, drug and alcohol use, and mental
health problems.2*77"12

Homeless youth face special challenges in sexual and
reproductive health, as they often have been sexually abused,
4. initiate sexual activity earlier than the general population,
and exhibit sexual risk behaviors. They are at increased risk
for being sexually exploited and trafficked.*° Nine percent of
runaway youth in a non-random sample of over 1600 youth
reported engaging in survival sex (the exchange of sex for
food, shelter, or other necessities) at some point in their lives.
A large national study found that 28% of youth living on the
street and 10% of youth living in shelters engaged in survival
sex,

Health Care Access
Health Care Access Highlights
Homeless youth experience multiple obstacles in
securing necessary health care. The transient status
of those who are homeless for extended periods of
time makes it difficult for them to establish a
relationship with a usual source of care and
complicates the process of enrolling in Medicaid or
securing other health insurance. Similar to young
people involved in the juvenile or criminal justice
system, homeless youth are heavily dependent on
Medicaid as a potential source of health insurance,
and many have remained uninsured. The ACA could
change that but is likely to do so only in states that
opt to expand Medicaid.

Pre-ACA

Although reliable data are not available, a strong likelihood
exists that many, perhaps most, homeless youth are uninsured,
especially if they are disconnected from families for prolonged
periods of time. In the past, youth who are away from home

for only a few days have been in a similar position to other
adolescents living at home: eligible for Medicaid if family
income is below 100% FPL (or a higher limit set by their state)
and they are age 18 or younger; otherwise they might be
covered on a family’s employer-based policy. Most homeless
youth disconnected from their families ~ both adolescents and
young adults ~ would be financially eligible for Medicaid,
even under the very low income thresholds prevalent in many
states for single adults. However, many obstacles exist that
have made it difficult for them to enroll even if eligible,
especially if they are unaccompanied minors.** These barriers
include complex application and enrollment procedures that
include requirements for a parent's signature and

documentation of parents’ income in the case of minors, as
well as a permanent address for contacting an applicant of any
age. Allowing a signed declaration in lieu of other
documentation of such matters as age, residency, family
composition, and income could facilitate the process
significantly. The difficulties associated with enrolling in
Medicaid have meant that many homeless youth have relied
on emergency rooms or sites offering free care funded by such
programs as Health Care for the Homeless to obtain whatever
health care they were able to access.”

Post-ACA

Whether the ACA helps homeless young adults join the ranks
of those with health insurance will depend to a great degree on
whether they are in a state that has chosen to expand Medicaid.
up to 133% FPL. Homeless adolescents under age 19 will be
cligible in every state up to 133% FPL beginning in 2014. Also
important — both for homeless adolescents and young adults —
will be whether the application and enrollment obstacles that
have stood in the way in the past are removed. Even though
some homeless young adults 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 for individuals with incomes up to 133%
FPL. Even in the states that do not, and continue to have very
low eligibility levels for single adults in Medicaid, homeless
young adults might be able to qualify. But either way, the
application and enrollment procedures, particularly the
requirement of a permanent address, as well as documentation
requirements, can still stand in the way of securing coverage.
In addition, many homeless youth will not have any means of
knowing what they are eligible for and how to go about
applying for it. As discussed below, the ACA requires siaies to
conduct outreach in Medicaid to vulnerable populations and
also to have streamlined application procedures, both of which
might be helpful to homeless youth.” One obstacle that
has been a problem in some states for homeless youth under
age 18 is that they have not been able to apply independently
of a parent. Recently, however, the federal agency responsible
for Medicaid has made clear that in any state where an
unaccompanied homeless youth is too young under state rules
to file a Medicaid application, any responsible adult (not
necessarily a parent or guardian) may do so on behalf of the
youth.”

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


implementing the ACA:
How Much Will it Help Vulnerable Adolescents & Young Adults?

E

&

Center for Adolescent Health & the Law
PO Box 3795

Chapel Hill, NC 27515-3795

ph. 919.968.8850

e-mail: info@cahl.org

ittp://wwiw.cal g

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

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 MJ. Implementing the Affordable Care Act:
How Much Will It Help Vulnerable 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, 2014.

Past Issue Briefs in This Series

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. Inwin, Jr. at NAHIC, and
Trina Anglin at the Maternal and Child Health Bureau for their
thoughtful review 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


Implementing the Affordable Care Act:
How Much Will It Help Vulnerable Adolescents & Young Adults?

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

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

INTRODUCTION

Many important provisions of the Patient Protection and
Affordable Care Act of 2010 (ACA) are being implemented
beginning in January 2014. The ACA will affect most
duals and busin ivthe
health insurance coverage to the uninsured and offering
important protections for many who already have or will gain
insurance, Although much of the ACA remains poorly
understood by the general population, its effects for vulnerable

States, expanding

populations of young people, sometimes called “disconnected
youth," are even less well known. The ACA has great
potential to benefit adolescents and young adults in general. It
will also have major implications for vulnerable adolescents
and young adults, helping many but leaving others without
essential coverage.

‘This issue brief explores the implications of the ACA for three
groups of vulnerable adolescents and young adults at special
risk of being disconnected from supportive adults and social
institutions: youth in or aging out of foster care; youth
involved in juvenile and criminal justice systems; and
homeless youth.’ For each group, the brief provides an
overview of demographic characteristics and health status, and
discusses access to health care and health insurance prior to
and post-ACA, It ends with a discussion of common themes
and upcoming challenges for the three populations, An
accompanying fact sheet summarizes the ACA’s implications
for these three groups.

YourH In FosTER CARE AND AGING OUT
Highlights
Hundreds of thousands of children and youth are in
foster care in the United States and tens of thousands of
adolescents and young adults age out of foster care
each year, Young people in foster care are
disproportionately members of racial and ethnic
minority groups and experience serious health problems
at higher rates than adolescents and young adults in the
general population. While in foster care, they are
generally eligible for and enrolled in Medicaid, but
historically health insurance coverage has been severely
limited once they age out. The ACA will reverse that
trend by requiring states to provide Medicaid coverage
for most youth as they age out of foster care up to age
26.

* Undocumented immigrant youth, who are also at risk of being
disconnected, are not eligible for insurance under any ACA
provisions.”

Demographics

Tn 2012, an estimated 400,000 children, adolescents, and young
adults were in foster care in the United States.* Nearly 40% of
youth in foster care, or slightly under 150,000, were

adolescents and young adults ages 12-20. A significant
number were in the older adolescent/young adult age group:
56,000 were ages 16 or 17; and nearly 17,000 were ages 18-202
A few of these youth entered foster care as very young
children; others entered as older children or as adolescents.
The total population was slightly more than half male, and
almost half female.’ Generally, foster youth are in a variety of
placements, including foster family homes (with relatives or
unrelated families), pre-adoptive homes, group homes,
institutions, and supervised independent living. Overall, the
vast majority of youth in foster care live in foster family
homes, but a much larger proportion of adolescents and young
adults live in group homes or institutions.? Youth in foster care
are disproportionately from racial and ethnic minority groups,
with 26% of the total Biack and 21% Hispanic’

Table 1: Foster Care Population by Race and Ethnicity, 2012
White 42% 164,990
Black or African American 26% 101,915
Hispanic (of any race) 21% 84,186
American Indian/Alaskan Native; Asian; or 3% 11,332
Native Hawaiian/Other Pacific islander
‘Two or more Races 6% 22,883
Unknown/Unable to Determine 3% 14,155

Adapted from “The AFCARS Report.”

Turnover in the foster care population is high, with
approximately 250,000 children and youth entering care in
2012 and almost as many leaving in the same year. Of those
who exited foster care in 2012, an estimated 23,396 or 10% left
by “emancipation,” or “aging out.” Prior to 2008, the age to
exit foster care was usually 18, with exceptions in some states.
In 2008, the federal Fostering Connections to Success and
Increasing Adoption Act was signed into law. The Act
provides additional support for older youth to remain in foster
care, in the form of continued federal foster care payments for
those ages 18 or older who meet certain placement conditions
and are engaged in activities designed to lead to
independence, including educational programs, employment,
and certain programs related to gaining employment
Continuation of support past age 18 can be critical to the safe
survival of former foster youth. As they transition into
adulthood, youth in foster care face major challenges,


implementing the ACA:
How Much Will it Help Vulnerable Adolescents & Young Adults?

12

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National Association of Counties. County Jails and the
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Implementing the ACA:
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two groups are very unlikely to have access either to
employer-based health insurance or to individual policies
through the health insurance exchanges. Homeless young
adults are unemployed at extremely high rates” and have little
or no income with which to purchase health insurance. Young
adults who have been involved in the criminal justice system
similarly have great difficulty gaining employment” and thus
have very limited ability to purchase health insurance, unless
they have the possibility of being on a parent's policy, Further,
the lowest-income young adults in states not expanding
Medicaid = those with incomes under 100% FPL’ = will notbe
eligible for subsidies in the health insurance exchanges. Thus,
in half the states, these two vulnerable groups are likely to fall
between the cracks and unlikely to gain health insurance as a
result of the ACA. This consequence provides an additional
important reason for states to expand Medicaid as, without
insurance, these young people are likely to seek care from
emergency rooms and local sources of free care, which place
additional burdens on state and local budgets.

Outreach and Enrollment

These three groups of vulnerable youth may be eligible for
Medicaid in several circumstances: for young adults ages 19
and older in states that are moving forward with the Medicaid
expansion; in all states for youth up through age 18 up to 133%
FPL; and for youth aging out of foster care up to age 26. Even
for the youth who are eligible, the complexities associated with
enrolling in Medicaid may prevent some from gaining
coverage. Under the current proposed regulation, youth
exiting foster care may not be eligible for Medicaid if they were
not in care and enrolled on their 18% birthday, or if they move
to a state other than the one where they were in care. Even if
eligible, former foster youth may not know about their
Medicaid eligibility or how to enroll. The same may be true
for all of the other vulnerable youth who are eligible for
Medicaid, either currently, or once the ACA is implemented.

The ACA includes two requirements that could be important
in this regard. First, states are required to “...conduct outreach
to and enroll in Medicaid/CHIP vulnerable and underserved
populations, including unaccompanied homeless youth . . ..”"”
Also, states are required to have streamlined application
procedures. In addition, agencies that have contact with these
young people ~ including child welfare agencies, juvenile
justice agencies, adult jails and prisons, homeless shelters, and
other agencies serving homeless people ~ could easily establish
procedures to help overcome the barriers and streamline the
appt S:

CONCLUSION

The ACA offers both the promise of important benefits and the
risk of continued disadvantage for three populations of
vulnerable youth. Most youth in and aging out of foster care
will be eligible for Medicaid up to age 26. Many young people
involved in the juvenile justice system will also be eligible for
Medicaid, at least up to age 19, unless they are confined in
public institutions; but young adults involved in the criminal
justice system will only qualify for Medicaid if their state
implements the Medicaid expansion option. Homeless youth
under age 19 are likely to be financially eligible for Medicaid
but may encounter significant obstacles in the application and
enrollment process. Homeless young adults, like those
involved in the justice system, are likely to have insurance
coverage only in states that expand Medicaid. Young people in
any of the three groups who are not eligible for Medicaid can
qualify for subsidies to purchase coverage through the
exchanges if their incomes are at least 100% FPL; otherwise
they will have no option available to them. Ensuring that
vulnerable populations of young people benefit from the full
promise of the ACA will depend on providing assistance to
individuals to secure health insurance they are eligible for as
well as advocacy to promote policies that will allow them to
gain the coverage they need.

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


{mplementing the ACA:
How Much Will it Help Vulnerable Adolescents & Young Adults?

Pre-ACA

Some young people involved in the juvenile and criminal
justice systems are eligible for (and may be enrolled in)
Medicaid prior to their entry into the system based on their
financial circumstances and other factors, but many ~
especially the young adults ~ are not.*5- States have been
required to cover children and adolescents through age 18 up
to 100% of the federal poverty level (FPL), but young adults
have been far less likely to qualify for Medicaid unless they
were pregnant or disabled, due to extremely low Medicaid
eligibility income thresholds Yor adults in most states prior to
the ACA.®

Most of those who are enrolled in Medicaid lose their
Medicaid coverage during incarceration due to a long-standing
provision of Medicaid law. Federal law prohibits use of federal
Medicaid funds to pay for services to “inmates of public
institutions.”%..”-*® Despite this provision, several options exist
for maintaining Medicaid eligibility for youth who are
detained on only a temporary basis, or for making sure that
their eligibility is reinstated immediately upon release. 6”
Possibilities include suspending rather than terminating
eligibility while a youth is in a public institution, using
presumptive eligibility to allow services to begin immediately
after a youth returns to the community while an application is
being processed, and requiring case managers or probation
officers to fill out Medicaid applications for youth leaving
juvenile residential placements.”

Ifa youth is in temporary detention, Medicaid eligibility may
be suspended rather than terminated, allowing coverage to
resume upon exit from detention without renewed application
and re-enrollment. ** Many facilities and state and local
authorities have not impiemented policies to make this
possible, however. Thus, many otherwise eligible youth have
not been able to benefit from Medicaid coverage to receive
health care services essential to treating their multiple physical
and mental health problems. As states update their computer
systems to facilitate compliance with the ACA, more states
may adopt a policy of suspending rather than terminating
Medicaid eligibility.

Consistent with these structural barriers to obtaining public or
private insurance, research has demonstrated that these young
people are medically underserved, and are less likely than
other young people to have medical homes. The National
Center on Correctional Health Care has detailed standards for
the provision of health care in juvenile facilities, and in adult
jails and prisons.“ © However, youth confined in juvenile
justice settings, in both short-term detention and longer-term
correctional placements, and young adults in jails and prisons
receive health care of widely varying quality and consistency.

‘This is true in spite of the fact that incarcerated individuals
have a constitutional right to health care. In a 2010 survey of
youth in residential placement, two-thirds reported a need for
health care, but more than one-third said they did not receive
needed care.#

Post-ACA

Access to health insurance and necessary health care for young
adults age 19 and older leaving the juvenile and criminal
justice systems is likely to depend largely on whether they live
ina state that chooses to implement the ACA Medicaid
expansion, because so many 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. Medicaid eligibility for young adults age 19
and older who are involved in the criminal justice system will
depend not only on whether they are incarcerated in a public
institution but also on whether they live ina state that
implements the Medicaid expansion.

Adolescents under age 19 will fare better than their older
counterparts, even in states that do not expand Medicaid for
adults, because the ACA requires all states to provide
Medicaid coverage for all children and adolescents through
age 18 up to 133% FPL beginning in 2014. Thus, young people
under age 19 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.”

Both adolescents and young adults with incomes too high to
qualify for Medicaid may be able to access health insurance
either on a parent's employer-based policy {if they are under
age 26) or through the policies available through the health
insurance exchanges being implemented under the ACA.
Subsidies may be available — in the form of premium tax
credits for those with incomes between 100% and 400% FPL
and cost-sharing assistance for those with incomes between
100% and 250% FPL ~ that make these policies more
affordable. Agencies and facilities in the juvenile and criminal
justice systems can play an important role in ensuring that
eligible youth do not fall through the cracks but are enrolled in
insurance coverage for which they are eligible, particularly as
they are leaving those systems. Having health insurance in
place so that health care appointments can proceed
immediately following return to the community is vital for
preventing recidivism, especially for young people with
mental disorders and substance abuse problems.

Center for Adolescent Health & the Law
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January 2014


implementing the ACA:
How Much Will it Help Vulnerable Adolescents & Young Adults?

YOuTH IN JUVENILE AND CRIMINAL JUSTICE SYSTEMS incarcerated in one of these settings.” Minorities are vastly
Highlights overrepresented, with African Americans making up 41% of

juveniles in the residential placements and 39% of young

Millions of adolescents and young adults in the United .
adults ages 20-24 in state and federal prisons and local jails. ?”

States have some contact with either the juvenile justice
system or the criminal justice system. For some the

contact is limited to an arrest, or a prosecution that leads Health Status

to no conviction or to release on probation, but many are Adolescents entering the juvenile justice system who are
detained or incarcerated in juvenile or adult facilities for detained or incarcerated generally have pre-existing health
brief or prolonged periods of time. These youth problems.” r#!28 Mental health issues, including suicide, are
experience high rates of numerous health concerns, of particular concern.”:** An estimated 60-65% of adolescents
especially mental health and substance abuse problems, in the juvenile justice system have a mental disorder, and

and widely varying access to the health care they need. among those with mental disorders, 20% of mental disorders
The implications of the ACA for this vulnerable population are considered “serious.”*!-*? In addition, they may also
depend on the specifics of their individual circumstances experience problems associated with sexual activity, substance
and the state in which they live. abuse, and violence at higher rates than their peers in the

general population. Although little information is available
specific to the young adult population within the justice
system, incarcerated adults generally experience many of the
same health problems as youth in the juvenile justice system.
Additionally, HIV is a concern among adult inmates, with a
prevalence rate higher than the general US population.

Demographics

In 2010, 1.6 million individuals under age 18 were arrested in
the United States.” These youth include both juvenile
delinquents who have committed offenses that would be
crimes for adults and status offenders who have committed
offenses “for children only,” such as school truancy or running
away from home. According to an FBI crime report, there were Health Care Access

2.8 million arrests of young adults ages 18-24 in 20112 Health Care Access Highlights

Multiple factors determine access to health care for
youth while they are in the juvenile and criminal justice
systems and after they exit those systems. These
include their individual socio-economic circumstances,
which state they live in, and what part of the system
they are involved in. Many young people involved in
the juvenile and criminal justice systems are living in
poverty or have very low family incomes. Responsibility
for providing health care to detained or incarcerated
adolescents and young adults rests mostly with the
states and focal communities in which the facilities are

The cases of most juveniles who are arrested do not go to trial,
and most cases result in probation without incarceration or
confinement.” Nevertheless, in 2010, there were over 70,000
juveniles ages 20 and younger in residential placements in the
juvenile justice system, including such sites as detention
centers, shelters, reception/diagnostic centers, group homes,
and boot camps.” Juvenile males outnumber females almost
seven to one in these residential placements. Large numbers
of young adults also are in federal or state prisons or local jails;
in 2010, for example, 73,000 young adults ages 18-19 were

Adolescents and Young Adults in Juvenile Residential Placement located, with significant variations in quality. Many
by Race, 2011 youth involved in these systems are not confined in
White Black Hispanic | Other | Total secure facilities, even if adjudicated or convicted. Some
12 or younger 41.6% 36.8% 14.0% 7.6% | 100% of these, who are living in non-secure residential
Tsay 325% 39.9% Da% 2.8% | 100% placements or in the community on probation or
parole, have Medicaid or private health insurance
18-20 15.6% | 20.6% 11.5% | 52.3% | 100% coverage, but many do not. in the future, the effects of
Total 28.3% 35.0% 19.9% | 16.8% | 100% the ACA for the poor and low-income youth involved

the juvenile or criminal justice system will turn largely
on whether or not they live in a state that implements
the Medicaid expansion for adults ages 19 and older.

Adapted from “Easy Access to the Census of Juveniles in Residential
Placement.””® Note: Does not include juveniles or young adults held
in adult jails or prisons.

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


Implementing the ACA:
How Much Will it Help Vulnerable Adolescents & Young Adults?

including lack of family support; employment and income
problems; inadequate or inappropriate living arrangements;
medical, dental, and mental health problems; and lack of
health insurance?

Health Status

Youth in and aging out of foster care experience many physical
and mental health problems at high rates, significantly higher
than the general population.2:* When compared with other
youth from the same socioeconomic backgrounds, those in
foster care have higher rates of physical and mental health
issues, including birth defects, developmental delays,
emotional adjustment problems, chronic physical disabilities
such as asthma and seizure disorders, malnutrition, dental
caries, and substance abuse, ”"?

Although estimates vary widely, all suggest that chronic
illness, disability, and mental health problems among foster
youth are prevalent at high rates. Estimates of the proportion
of foster youth who have mental health problems when
entering care, while in care, or in their lifetimes range from
30% to 80%; more than 30% of older adolescents in foster care
have a chronic illness or disability.° ! Some of their health
problems are directly related to factors, such as physical or
sexual abuse, which led to their placement in foster care; others
arise during placement.

Health Care Access
Health Care Access Highlights
Youth in foster care and aging out often encounter
significant problems gaining access to health care,
and frequently lack access to health care providers
experienced in caring for a population with their
particular needs. While in foster care, virtually ail
adolescents are eligible for Medicaid. Once they age
out, however, the picture changes significantly, with
studies finding that only about half of foster youth
had health insurance after they exited care.°
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, although challenges
in accessing this coverage will remain for this
vulnerable population.”

Pre-ACA

Historically, children and adolescents in foster care have been
eligible for Medicaid, removing at least one of many obstacles
to receiving the health care they need. However, most of these
young people lost their Medicaid coverage as soon as they
“aged out” of foster care, usually at age 18, with some states

allowing voluntary continuation in care until age 21. After
losing the Medicaid coverage they were eligible for by virtue of
being in foster care, many former foster youth were unable to
secure health insurance by other means, such as through
Medicaid or private insurance. Medicaid income eligibility
levels for single adults who were neither pregnant nor
disabled have persistently been extremely low in most states;
and because many former foster youth experience difficulty in
gaining employment, especially with benefits, employer-based
coverage is also often unavailable to them. A major

fongitud! ‘outh in 2010 found that
nearly one-half lacked health insurance at age 23 or 24,*
consistent with the findings of earlier studies.'* The federal
Foster Care Independence Act enacted in 1999 included a
“Medicaid expansion option,” that allowed states to continue
Medicaid coverage for former foster youth to age 21. As of
January 2011, 33 states had implemented this option.”

study of former

Post-ACA

The ACA offers an important opportunity to improve this
situation by requiring all states to provide continued Medicaid
coverage for former foster youth to age 26.'* This paraileis the
ACA provision allowing young adults to remain on a parent's
health insurance policy to age 26, which has resulted in
millions of additional young, adults gaining private health
insurance since it went into effect in 2010." In January 2013,
HHS issued a proposed regulation to implement this ACA
provision for former foster youth?’ as of January 1, 2014 this
regulation for former foster youth had not yet become final.

According to the proposed regulation, states must provide
Medicaid coverage to individuals who are under age 26, are
not otherwise eligible for and enrolled under Medicaid’s
mandatory categories, and were in foster care and enrolled in
Medicaid when they reached age 18 (or a later age for aging
out of foster care, as specified by their state). As written, the
coverage would be limited to former foster youth applying for
Medicaid in the state in which they had been in foster care.
However, the proposed regulation would provide states with
the option of offering the coverage to youth who had been in
foster care in any state, but would not require them to do so.
There are no financial eligibility (“income or resources”)
requirements for a former foster youth to qualify for this
Medicaid coverage, and a former foster youth who meets the
other requirements may apply at any time up to age 26, The
Centers for Medicare and Medicaid Services has estimated that
by 2017 an additional 74,000 former foster youth will be
enrolled in Medicaid under this provision.”

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


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Kaiser Commission on Medicaid and the Uninsured, Issue
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http://kaiserfamilyfoundation files wordpress.com/2013/02/84
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Cindy Mann, Centers for Medicare and Medicaid Services,
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http://www.soc.umn.edu/~uggen/Uggen_Wakefield_Chap_05.
pdf.

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

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