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Adolescent Health Care: Aligning Policy with Practicality

Serving adolescents properly with health care has always been difficult. Utilization of adolescent health care services (AHCS) is far below where it should be, to the detriment not only of patients, but to the nation's health as a whole. When we know that illnesses often begin in adolescence, and that they could be avoided – or at least detected early and treated at that time—why are they so underutilized?

An article last year in Pediatrics by Hargreaves et al. cites a survey of adolescents and parents. What were the impediments to seeking health care for the teenagers? The results were interesting.

  • 37.2% - unmet need perceived to be of low importance
  • 32.0% - non-financial access problems
  • 22.7% - negative consequences of health care
  • 14.8% - cost

Now, that's pretty amazing. It would seem that beliefs and inconvenience were the major reasons these kids didn't get the care that experts believe they needed. A mere 15% said that the money it would cost to get these services was an impediment.

This is an inconvenient conclusion. We love to solve problems by throwing money at them, but these results would seem to suggest that money isn't the issue. Does that mean we will actually have to think this thing through? What a bother that would be!

My thought is that, yes, we'll have to think it through, but not to worry, at the end we can throw some money at the problem with some hope of success, although not immediate. These things do take time. So here's the way I put it together.

First, I bet that the newness of adolescent medicine (AM) as a concept is part of the difficulty. Instead of simply a way station between childhood and adulthood that must be endured, we now see adolescence as a separate stage of life, with its own epidemiology that features major components such as injuries, suicide, drug and alcohol problems, mental and behavioral disorders, and sexual/reproductive issues. It is only in recent years have we have recognized that primary prevention, early detection, and interventions in these issues can not only be effective in helping the kids in the present time, but can also pay dividends in better health for decades to come. It is also only in recent decades that adolescent medicine (AM) has been seen as a distinct entity to be served by pediatricians, with its own subspecialty professionals as sources of instruction and as providers of care to difficult cases. In other words, it's new. Indeed, when I was in training in pediatrics at UCSF, we were not allowed to see patients after their 13th birthday! That's how new it is.

I also bet that this newness hasn't filtered down to the general populace fully. The families and the patients are not aware that there are issues in adolescence that should be approached medically. Adolescents typically feel invulnerable as their prefrontal cortexes are still myelinating, so they don't want to come in, and families just don't realize the potential value of ACHS. In addition, I'm sure the difficulties of confidentiality and embarrassment dissuade adolescents from accessing the services.

Also, note the 32% of the survey who said there were non-financial access problems. Lots of patients don't think of the pediatrician as someone to turn to for adolescent problems—although this is changing—and many pediatricians don't really like to deal with adolescent problems that much, and there are many places where full fledged pediatric services aren't available.

OK, so that's “beliefs” and “access,” rather than a direct financial barrier, which only 15% cite as the problem. Still, it seems to me as a health care policy analyst who tends often to think in economic terms, that money can still be an important part of the problem. And as a usually liberal Democrat, I think I can see my way clear to throw money at the problem. But if we are going to do that, we will have to diminish the salience of that 15% number.

First of all, I'm not sure that 15% is the right number for people who are deterred by cost. People do a lot of rationalization when they give reasons for acting as they did. It is very difficult for many people to think, “I didn't give my kid enough care because I wanted to save money.” It's more comfortable to think, “I didn't go to the doctor because I didn't think it would help,” or, “I didn't think doctors took care of that,” or, “I figured he would grow out of it.” Those ex post facto explanations still allow a parent to think that he or she was acting as a good parent. So I'm pretty sure that the 15% number is factitiously low.

Second, even though the ACA was supposed to make care “affordable,” we all know that there are still significant financial barriers to care. Well child visits are now free, but many teens and young adults still lack coverage, and for those who have it, high deductibles and high coinsurance are still problems, many policies are not covered by the ACA and have even higher barriers, and coverage of just those conditions often experienced by teens—mental health, behavioral, and sexual/reproductive services—are often under-covered or uncovered.

So, I would contend that direct financial barriers are still a problem, much in excess of the 15% reported who are affected by it.

Indirect effects of insufficient financing are also important. Clinicians are paid poorly for ACHS. It is well known that procedural specialties are more generously paid than the so-called cognitive specialties, which would include providers of ACHS. But even within the cognitive specialists, ACHS services are particularly undervalued. For instance, there are special billing codes for preventive care services—that is, well child visits. It is so, so much harder to see a 14 year old than a 7 year old. Yet the clinician is paid only a few dollars more to see the 14 year old, which is ridiculous. It is just hard to get paid for visits where the clinician does a pelvic exam, or where the clinician delves into a teen's depression, which over 10% of teens have. For payment, then, a case could be made for AHCS being the lowest of the low.

What does this low payment pattern lead to? For one thing, it leads to general pediatricians providing fewer AHCS than they otherwise would. That's just straight economics. If you are paid poorly for a service, you will tend not to encourage patients to patronize you for that service.

Second, well-financed services can use their money to construct attractive and even luxurious physical settings, to employ a host of aides, and to advertise to the public. I challenge anyone to think of AHCS settings and advertising to rival that of cardiac surgery.

Third, practitioners of financially favored fields hold positions of great respect in society. They are revered. It is hard to think of someone in AH being revered for preventing a suicide.

Fourth, physicians in training vie for positions in the fellowships that will grant them not only the ability to do good, but the ability to do well. AH fellowships are subject to much less demand even though there are fewer such positions available. It is hard for someone to choose a fellowship for three years at the end of which one will be qualified to provide services that will earn one less than one could make at the beginning of the fellowship from being a general pediatrician. Specialists in AM are generally not the major purveyors of ACHS; general pediatricians generally do that. But it is the graduates of the AH fellowships who will train the general pediatricians and give them enthusiasm for the field. As it is, however, training in AM for the primary care pediatricians is far from extensive, as training programs continue to concentrate on hospital-based services and specialties. If the financial rewards were more attractive, basic economics tells us that enthusiasm would be greater.

In sum, then, although patients might not cite financial obstacles as the key for their not obtaining services, there is a strong basis for thinking that if the field were better financed, increased utilization would follow.

What to do, then? Here are just a few suggestions, just illustrative, not definitive:

  • Change the focus of health care cost controls when it comes to AHCS. For much of medicine currently, the aim is to cut costs. For AHCS, the aim should be to increase costs. One could double or triple the cost of AHCS and it would have no impact whatsoever in the national health expenditures. Increasing expenditures would establish a better balance of expenditures and result in better health and eventually lower costs, as adult health improved and costs declined as the well-served adolescents age.
  • Change the ACA provisions for AHCS. Make all outpatient visits for teens have no deductible and only minor copays.
  • Equalize physical and mental health payments for teens.
  • Increase the requirements for AH training in all pediatrics residency programs. Introduce business case training in these programs to teach future primary care pediatricians how they can make money in adolescent health.
  • Change the Relative Value Units assigned to teen well visits – I would increase them by at least 50%.
  • Develop a set of standards for health status for adolescents under the care of larger health care institutions, and require that measurements be taken under supervision at regular times, and that the results be published.
  • Institute Pay For Performance measures specific to AH applicable for smaller practices, and require insurers to pay significant amounts to practices who achieve measures in stepped amounts according to percentile.

AH is a lot more important than people realize. There is a lot that can be improved by grants and special programs, I'm sure. But for a long lasting and relatively simple effort, I would support the basics of human economic theory – pay them more, and measure the results.
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Budd Shenkin is a public health professional who has almost forty years of experience in the health world, spanning the sectors of pediatric practice, health administration, and health policy. He graduated from the Goldman School of Public Policy with a Master of Public Policy in 1971.

This essay first appeared on his blog, Budd's Blog.

Estate Taxes Vital Tool for Fighting Income Inequality, Raising Revenue

Alice and Jim Walton, above, are each among the 20 richest people in the world, each valued at over $32 Billion. They owe their wealth to the inheritance of the estate of their father, Sam Walton, of Wal-Mart fame.

It’s no secret that the past thirty years have been tough ones for state and local governments looking to preserve revenue for key public services. The ideologically-driven assault against taxes of any stripe have not only reduced the ability of state and local governments to fund vital public safety, infrastructure, and public health initiatives, but it has also hampered the ability of governments to promote equality of opportunity in their jurisdictions, a key goal of an equitable system of taxation. An especially damaging tax reduction has been the 2001 Bush Administration estate tax reductions.

The value of an estate tax is simple to understand from an equity standpoint: the most straightforward way to limit intergenerational concentration of wealth is to limit the ability of the rich to bequeath large sums of money to other rich folks like themselves (usually their children).
Unfortunately, anti-government advocates have worked hard to preserve the fortunes of wealthy children by launching a fierce war of words against it. Giving it the new label of the “death tax,” these right-wing radicals shifted the conversation from the problem of income inequality to a sympathy for the unfortunate rich man who was being “taxed twice” on his income through a tax that is levied after his death.

No matter that federal estate taxes only apply to estates of $5.45 million and above in 2016. No matter that this argument of “double taxation” is never mentioned around sales taxes, which fall heavily on the poor. No, the estate tax has become a particular source of derision by anti-tax advocates, leading up to the 2001 federal cut that applied to the very rich who were then subjected to the tax.

Lost in the important conversation about income inequality, however, is the fact that the estate tax is also a significant revenue generator for state and local governments. When the federal government gutted its estate tax in 2001, a number of state governments decided to institute their own estate taxes. These taxes apply to estates at their lowest from $675,000 and up (New Jersey) to their highest at $5.45 million and up (Delaware, Hawaii, and Maine).

These taxes have proven to be significant revenue generators. In 2015, New York and Pennsylvania each raised over $1 billion in revenue from their estate taxes. Estimates by the Center on Budget and Policy Priorities say that if California instituted an estate tax with a fairly high exemption of $3.5 million (meaning it would only apply to estates worth that much or more), the state would raise a similar amount per year. A lower exemption that applied to all millionaires would generate $1.7 billion in revenue a year. For perspective, that is the same size as the state’s annual expenditures on business, consumer services, and housing.

The estate tax is an equitable, vital tool for policymakers to both reduce income inequality and generate revenue for public services. States like California should seriously consider reinstating the estate tax if they are truly committed to ensuring an even playing field for all their residents and not leaving dollars on the table that can be put to good public use.
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Rob Moore is a Master of Public Policy candidate at the Goldman School of Public Policy and an editor at PolicyMatters Journal where this article was originally posted.

Voting for a Healthier Community

Over the past decade, the Alameda County Public Health Department (ACPHD) has been at the forefront of efforts to re-conceptualize the role of a public health agency. In 2008, it adopted a health equity framework that focuses not only on the traditional downstream factors that influence individual and community health outcomes (e.g., individual health behaviors like smoking), but also on the upstream or socio-ecological factors that determine health (e.g., discriminatory beliefs, institutional power, and social inequities). In order to monitor and address the impact of socio-ecological factors on health outcomes in the County, ACPHD has developed and implemented a number of initiatives and programs aimed at addressing the social determinants of health. 

Despite designing and implementing a number of community capacity building and civic engagement programs over the past decade, efforts to monitor the levels of voter participation—a key indicator of political empowerment and social capital—have been very limited. Troubled by a recent drop in the County’s voter turnout rates, ACPHD’s Legislative Council Coordinator, Pam Willow (’01), brought me on to work on a new Voter Turnout Initiative. 

The goal of this initiative is to learn more about how voter participation affects both community and individual health; what the Department can do to address low levels of voter registration and turnout; and how it might implement a pilot program aimed at improving voter participation rates in the upcoming 2016 elections, particularly among low-income people of color who have historically been underrepresented in the political system. 

Working on this project for my Applied Policy Analysis (APA) has been an incredible learning experience that has required me to use every skill in my policy analysis tool set. I applied my newly-acquired quantitative skills to identify emerging trends in voter participation as well as connections between voter participation rates and health outcomes. Most of my work, however, has involved interviewing much of ACPHD’s staff, its sister agencies, community partners, and clinical practitioners. Here my Introduction to Policy Analysis (IPA) experience has been invaluable as it proved to be a training ground for working within an agency context, learning about interview protocols, and practicing how to organize and synthesize large amounts of qualitative data into concise and useful pieces of information for a decisionmaker. Through this process, I have conducted an organizational analysis of ACPHD’s operational capacity and resources to identify ways in which different public health programs can contribute to the work of the initiative’s three phases: voter registration, public education, and voter turnout. 

I am now in the process of using all of the research I have conducted to inform the design of an implementation plan that ACPHD can use. I recently learned that the recommendations I put forth in my APA report will be put into place this summer and fall in the lead up to the November general election. In fact, we are recruiting first-year GSPP students to serve as interns that will implement and evaluate the plan in the coming months. Reflecting back, this project truly feels like the culmination of my two years of professional development at the Goldman School. The project seeks to see a problem as an opportunity, to use policy analysis to inform decisionmaking, and to create positive change in our community.

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Vanessa Cedeño received her Masters in Public Policy from the Goldman School in 2016 and is currently a policy consultant at Alameda County Public Health Department.

This article originally appeared in the Spring 2016 edition of Policy Notes.

The Millennial Tipping Point

In more ways than one, young Americans are about to have their moment. 

Millennials (typically thought of as those born between 1982 and 2000) now make up the largest group of consumers in the economy, with younger households disproportionately driving American consumer spending.1 Likewise, for the first time in history, Millennials also make up the same proportion of the American electorate as the Baby Boomers. 

In every recent election, we have seen some variation of Millennial “scolding,” with pundits lamenting the fact that this generation just isn’t as engaged as previous generations. About half of registered Millennial voters don’t identify with either major political party, meaning that their views and preferences aren’t necessarily represented in party platforms. 

For the 2016 election, however, the premise that young voters won’t turn out doesn’t seem to be holding true. Looking at the primary elections and caucuses held to-date, young people in both parties are turning out in numbers on par with the high youth turnout in the 2008 election. Senator Bernie Sanders has dominated among the youth vote, with Secretary Hillary Clinton and Donald Trump following in second and third. 

It remains unclear, however, what youth turnout and support may look like in the general election. In a hypothetical Clinton vs. Trump face off in November, according to current Reuters polling,2 Secretary Clinton would take the youth vote by a 2-1 margin. The second largest group in the same poll—a good 24 percent of young Americans—say they do not know who they would support or would not vote. This may highlight the lack of strong party identification among young voters, or may underscore a lack of enthusiasm among Millennial voters for these Presidential candidates. 

Millennials have a distinct agenda for the next President, with a strong focus on the economy and college affordability. This is the most educated generation in American history, but one that has been handicapped by a distinct set of economic obstacles. An unfavorable labor market has made it difficult for students to pay off debt—wages for college graduates have grown 60 percent more slowly than those of the general population.3 

Young people are looking for a leader who will prioritize their long-term financial security. It is unclear whether Millennials will turn out in November 2016, and whether turning out will be enough to get them what they want. What is clear, however, is that sometime in the not-too-distant future, the Millennial voting bloc will arrive on the scene, and American politics for the next 40 years will be dominated by their priorities and worldviews.

  1. J P Morgan Chase, Local Consumer Commerce. December 2015. Available online: http://bit.ly/JPMorgan-LocalConsumerCommerce  
  2. http://bit.ly/ReutersPoll-March2016 
  3. The Atlantic, Why are Wages for College Grads So Terrible? Available online: http://bit.ly/Atlantic-CollegeGradWages

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Sarah Swanbeck is the Executive Director of the Center on Governing & Investing in the Future (CGIF). She received her Masters in Public Policy from the Goldman School in 2011.

This article originally appeared in the Spring 2016 edition of Policy Notes.