Caring for the “Young Invincibles”

The term “young invincibles” has been used—most recently during the health care reform debates—to describe young adults and their perception that they are not at risk for poor health. The analysis of emergency department use by young adults over the last decade by Fortuna et al. in this issue1 challenges this invincibility. Using data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Care Survey, Fortuna et al. found that one in five health care visits among young adults occur in the emergency room setting and that young adults disproportionately receive care for non-injury-related illnesses in the emergency department compared to both younger and older age groups. Most concerning is that rates of emergency department use over the last decade suggest a worsening of this trend. Contrary to the common belief that young adults are a population at low risk for disease, many young adults already have a chronic illness, and many more are establishing lifestyle habits that affect their future risk of disease. Approximately 15% of young adults are already affected by a chronic disease, and 1 out of every 20 young adults rate their health as poor or report a limitation in functional status secondary to a chronic disease.2 Asthma, arthritis, and hypertension are the most common of these chronic diseases; however, diseases that are more commonly found in older adults such as diabetes, cancer, and cardiovascular disease also affect some young adults.2 Risk factors for chronic illness, when present in young adulthood, often place individuals at greater lifetime risk of complications, especially when poorly controlled. Over the last 3 decades, mortality from cardiovascular disease has declined in all adult age groups except young adults; the rising rates of poorly controlled cardiovascular risk factors in young adults appear to explain this observation.3 Over a quarter of young men and women smoke.2 Young adults have a rising prevalence of obesity and low physical activity, which puts them at even greater risk for future chronic diseases,2 and the high rates of obesity among today’s teenagers suggest that the need to treat obesity-related chronic illness during the young adult period will only intensify in the future.4 Fortuna et al. found the highest rates of emergency room use occurred among African Americans, with nearly half of African-American men receiving their medical care in the emergency department.1 As with other young adults, much of this care was for non-injury diagnoses, highlighting the need for increased access to ambulatory care for this population. Cardiovascular disease is a major contributor to racial disparities in health,5 and the presence of cardiovascular risk factors during young adulthood and their poor control at this age are more common in race/ethnic minority populations.6 African Americans have the highest prevalence of hypertension among all race/ethnic groups, and differences by race in rates of hypertension are most pronounced during young adulthood.6 Overall, young adults have far lower rates of awareness, treatment, and control of their hypertension than middle-aged and older adults, and the rates of control are lowest among young African Americans and Mexican Americans.7 The consequences of poorly controlled blood pressure can lead to significant morbidity and mortality, even at these younger ages. One in 100 adult African-American men and women develops heart failure before age 50, with hypertension during young adulthood a primary risk factor.8 African Americans and Latinos aged 20–44 are at higher risk for stroke compared with whites,9 another complication of poorly controlled blood pressure at young ages. The high rates of these hypertension-related conditions in African Americans and Latinos suggest that improving access to preventive care in young adulthood is a crucial component in addressing race/ethnic disparities in health, but strategies for increasing access are likely to be complex. Lack of insurance is a major barrier to ambulatory care among young adults in general, and African Americans and Latinos in particular.10 However, even among the insured, young African American, particularly African American men, have lower utilization of ambulatory care and preventive care,10 highlighting the additional obstacles faced in these populations. Fifty percent of African Americans and Latino young adults live below 200% of the federal poverty line.2 Moreover, from 1999 to 2006 incarceration among young men increased by 15% and young women by 25%, with African Americans and Latinos disproportionately affected.2 Poverty and incarceration both increase the risk of disease and serve as additional barriers to accessing the medical system in order to provide quality preventive care.11 Access to culturally competent care and awareness of risk profiles in race/ethnic minorities among health care providers are critical additional aspects that deserve attention in efforts to reduce race/ethnic disparities in care.10 With a third of young adults currently uninsured, the young invincibles stand to benefit enormously from the expanded coverage in the historic health care reform legislation. However, the work of Fortuna et al. suggests that increased access to insurance for young adults may not be sufficient to change the current patterns of emergency use. Enhancing ambulatory and preventive care access for young adults is likely to require a multi-faceted approach that addresses patient, provider, health system, and societal factors. Because this young adult period is when the foundation for future health behaviors and health status is established, improved access to ambulatory and preventive care could have its greatest impact at this stage. Though challenging, identifying the most effective means for providing high-quality ambulatory care for young adults is critical to the health of the nation and our future.