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• W2013651410 abstract "See Related Article p. 23 The transition from adolescence to adulthood is becoming increasingly complex, as a changing economy requires a more highly skilled workforce [[1]The Conference Board, Inc., the Partnership for 21st Century Skills, Corporate Voices for Working Families, and the Society for Human Resource Management. Are they really ready to work? Employers' perspectives on the basic knowledge and applied skills of new entrants to the 21st century U.S. workforce. Available at: http://www.cvworkingfamilies.org/downloads/FINAL_PDF_9_29_06.pdfGoogle Scholar]. The ability to manage one's health is a critical aspect of a successful transition. This is particularly true for youth with special health care needs (YSHCN), who, by definition, depend on a range of health care services for normal functioning and healthy development. National data for all children and youth with special health care needs show this population to have twice the number of physician visits, five times as many prescribed medications, and more than four times as many hospital visits annually as peers without special needs [[2]Newacheck P. Kim S. A national profile of health care utilization and expenditures for children with special health care needs.Arch Pediatr Adolesc Med. 2005; 159: 10-17Crossref PubMed Scopus (375) Google Scholar]. The article by Lotstein and colleagues in this issue of the Journal adds to our understanding of how these youths are faring in their transition [[3]Lotstein D.S. Inkelas M. Hays R.D. et al.Access to care for youth with special health care needs in the transition to adulthood.J Adolesc Health. 2008; 43: 23-29Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar]. As they transition to adulthood, YSHCN require comprehensive, developmentally appropriate services. Having health insurance plays a critical role in ensuring access to these services [4American Academy of Pediatrics, American Academy of Family Physicians and American College of Physicians–American Society of Internal MedicineA consensus statement on health care transitions for young adults with special health care needs.Pediatrics. 2002; 110: 1304-1306PubMed Google Scholar, 5Society for Adolescent MedicineTransition to adult health care for adolescents and young adults with chronic conditions A position paper.J Adolesc Health. 2003; 33: 309-311Abstract Full Text Full Text PDF PubMed Scopus (494) Google Scholar]. Young adults have the lowest rates of insurance of any age group [6Adams S.H. Newacheck P.W. Park M.J. et al.Health insurance across vulnerable ages: Patterns and disparities from adolescence to the early 30s.Pediatrics. 2007; 119: e1033-e1039Crossref PubMed Scopus (63) Google Scholar, 7Collins S.R. Schoen C. Kriss J.L. Doty M.M. Mahato B. Issue brief: Rite of passage? Why young adults become uninsured and how new policies can help. The Commonwealth Fund, New York, NY2007http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=514761Google Scholar]. The consequences of lack of insurance are particularly troubling for those with special health care needs. Uninsured young adults with a disability report unmet need at rates two to three times the rates for other young adults with a disability and for uninsured young adults without a disability [[8]Callahan S.T. Cooper W.O. Access to health care for young adults with disabling chronic conditions.Arch Pediatr Adolesc Med. 2006; 160: 178-181Crossref PubMed Scopus (74) Google Scholar]. In negotiating the health care system, YSHCN face many challenges, partly because many aspects of the safety-net programs that serve children and adolescents change abruptly in these individuals' late adolescence or disappear altogether. For example, adolescents with disabilities who qualify for the Children's Supplemental Security Income (SSI) program are generally also eligible for Medicaid. However, to stay in the program, at age 18 years SSI recipients must meet criteria for adult SSI. An estimated one-third of these adolescents fail to meet adult SSI criteria, in turn jeopardizing their Medicaid eligibility [9Schulzinger R. Youth with disabilities in transition: Health insurance options and obstacles. Center for Policy and Partnerships, Institute for Child Health Policy, Gainesville, FL2000http://hctransitions.ichp.ufl.edu/policypapers/HealthInsuranceOptions.pdfGoogle Scholar, 10Bazelon Center for Mental Health LawMoving on: An analysis of federal programs funding services to assist transition-age youth with serious mental health conditions.2005http://www.bazelon.org/publications/movingon/Analysis.pdfGoogle Scholar]. Those who do retain Medicaid eligibility usually receive an “adult” benefits package that is much less comprehensive than those for children and adolescents [[11]Williams B. Tolbert J. Aging out of EPSDT: Issues for young adults with disabilities. Kaiser Commission on Medicaid and the Uninsured, Washington, DC2007http://www.kff.org/medicaid/upload/7491.pdfGoogle Scholar]. Characteristics of these programs, such as eligibility criteria and benefits, vary by state, making it more difficult for youth to manage the transition to adult programs. Those YSHCN who successfully retain insurance still face other barriers. Although insurance is essential, it is not sufficient to ensure that needed services are received. Access involves other factors, such as a usual source of care and trained providers [4American Academy of Pediatrics, American Academy of Family Physicians and American College of Physicians–American Society of Internal MedicineA consensus statement on health care transitions for young adults with special health care needs.Pediatrics. 2002; 110: 1304-1306PubMed Google Scholar, 5Society for Adolescent MedicineTransition to adult health care for adolescents and young adults with chronic conditions A position paper.J Adolesc Health. 2003; 33: 309-311Abstract Full Text Full Text PDF PubMed Scopus (494) Google Scholar]. A recent analysis of national data shows that similar proportions of young adults with asthma experience delays in access to care because of financial and nonfinancial barriers [[12]Scal P. Davern M. Ireland M. Park K. Transition to adulthood: Delays and unmet needs among adolescents and young adults with asthma.Pediatrics. 2008; 152: 471-475Abstract Full Text Full Text PDF Scopus (46) Google Scholar]. Lotstein and colleagues examined multiple aspects of access to care among low-income YSHCN served by Title V, a federal–state program that facilitates access to services for children and adolescents with special health care needs. The authors assessed insurance as well other indicators of access: among the individuals that they studied, 24% lacked a usual source of care; 27% had foregone needed care since turning 21 years of age; and 40% had had an insurance gap since turning age 21. Overall, two-thirds of the youth experienced an “adverse event,” defined as lacking any measure of access examined in the study. Two-thirds of those lacking a usual source of care were insured, underscoring that insurance is necessary but not sufficient to secure access to care [[3]Lotstein D.S. Inkelas M. Hays R.D. et al.Access to care for youth with special health care needs in the transition to adulthood.J Adolesc Health. 2008; 43: 23-29Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar]. The four-domain transition framework of transition outcomes presented by Lotstein and colleagues is a useful contribution that can guide research and policy: (1) ongoing access to age- and disease-appropriate health care providers; (2) access to uninterrupted, affordable health insurance; (3) development of disease self-management skills; and (4) access to age-appropriate education and vocational opportunities to allow economic self-sufficiency. Although this article focuses on the first two domains, the framework recognizes that these young adults require skills as well as support from systems outside of health care [[3]Lotstein D.S. Inkelas M. Hays R.D. et al.Access to care for youth with special health care needs in the transition to adulthood.J Adolesc Health. 2008; 43: 23-29Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar], which reflects the field's increasing focus on positive function of individuals rather than a sole focus on receipt of needed health care services [[13]Stewart D. Stavness C. King G. Antle B. et al.A critical appraisal of literature Reviews about the transition to adulthood for youth with disabilities.Phys Occup Ther Pediatr. 2006; 26: 5-24Crossref PubMed Google Scholar]. This approach recognizes that there are many health issues that merit special focus during young adulthood, such as injury and substance use [[14]Park M.J. Paul Mulye T. Adams S.H. et al.The health status of young adults in the United States.J Adolesc Health. 2006; 39: 305-317Abstract Full Text Full Text PDF PubMed Scopus (300) Google Scholar]. This framework also points to the importance of positive mental function, especially for YSHCN whose conditions include mental health problems and learning disabilities. Data from one state suggest that youth with serious emotional disturbances face considerable barriers in transitioning to adult mental health service systems [[15]Heflinger C.A. Hoffman C. Transition age youth in publicly funded systems: Identifying high-risk youth for policy planning and improved service delivery.J Behav Health Serv Res. 2006; (December 26, first published online (DOI# 10.1007/s11414-006-9042-2))Google Scholar]. Mental health diagnoses account for the majority of diagnoses in children's SSI [[11]Williams B. Tolbert J. Aging out of EPSDT: Issues for young adults with disabilities. Kaiser Commission on Medicaid and the Uninsured, Washington, DC2007http://www.kff.org/medicaid/upload/7491.pdfGoogle Scholar]. Greater coordination between different systems serving YSHCN will be critical given the increased demand for a workforce with technological and cognitive skills (e.g., analytic and problem-solving skills) [[1]The Conference Board, Inc., the Partnership for 21st Century Skills, Corporate Voices for Working Families, and the Society for Human Resource Management. Are they really ready to work? Employers' perspectives on the basic knowledge and applied skills of new entrants to the 21st century U.S. workforce. Available at: http://www.cvworkingfamilies.org/downloads/FINAL_PDF_9_29_06.pdfGoogle Scholar]. The positive association between receipt of special education services and current SSI enrollment deserves further study. Although the authors note limitations that make interpreting these findings difficult, the study presents a base for future research to explore the role of non–health care programs in facilitating a healthy transition [[3]Lotstein D.S. Inkelas M. Hays R.D. et al.Access to care for youth with special health care needs in the transition to adulthood.J Adolesc Health. 2008; 43: 23-29Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar]. Lotstein and colleagues' article points to additional steps to be taken next in research and policy. Low-income young adults with special health care needs still face considerable barriers in financial access to care, demonstrating the ongoing need for changes in the system that finances and delivers health care. Beyond insurance, greater efforts are needed to increase the number of clinicians available to serve these young adults. The finding that nearly one-third of young adults had not changed providers since aging out of the program suggests an extended transition to adult care. Thus it is important to develop models of care that involve families of nonminors. A study of the San Francisco program to extend Medicaid coverage to young adults found that 25% of participants were enrolled by their parents or other relatives [[16]Rising J.P. Colon-Hopkins C. Neumann A. et al.Healthy young adults: Description and use of an innovative health insurance program.J Adolesc Health. 2007; 41: 350-356Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar]. Although Lotstein and colleagues acknowledge the need for larger studies, this work serves as an important reminder of the complex needs of the YSHCN population. Efforts to facilitate a healthy transition for the YSHCN population must address a range of barriers to care, while promoting healthy development that encourages optimal adult functioning. Access to Care for Youth with Special Health Care Needs in the Transition to AdulthoodJournal of Adolescent HealthVol. 43Issue 1PreviewTo describe access to care and identify factors associated with access for low-income young adults who aged out of a public program for children with special health care needs (CSHCN). Full-Text PDF" @default.
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