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Adolescent care standards and state CHIP efforts.

Although widely thought of as a health insurance program for younger children, the State Children's Health Children's Health Definition

Children's health encompasses the physical, mental, emotional, and social well-being of children from infancy through adolescence.
 Insurance Program (CHIP) also has enormous potential to expand insurance coverage, including coverage of reproductive health Within the framework of WHO's definition of health[1] as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, reproductive health, or sexual health/hygiene  guidance and services, to millions of uninsured teenagers. The extent to which CHIP meets this potential will largely be determined by the individual states, which have considerable discretion in designing their own efforts and benefit packages. For guidance in making critical coverage decisions, states can look to several comprehensive guidelines for adolescent health care, including reproductive health services, developed in recent years.

Congress established the State Children's Health Insurance Program (CHIP) in 1997 in response to data indicating that there were over 10 million uninsured children in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area.  that year--including 2.7 million teenagers between the ages of 13 and 18 (1.3 million females and 1.4 million males). With nearly $40 billion in federal funds Federal Funds

Funds deposited to regional Federal Reserve Banks by commercial banks, including funds in excess of reserve requirements.

These non-interest bearing deposits are lent out at the Fed funds rate to other banks unable to meet overnight reserve
 available to them over 10 years, the Years, The

the seven decades of Eleanor Pargiter’s life. [Br. Lit.: Benét, 1109]

See : Time
 states are charged with establishing CHIP programs, which may enroll children under age 19 in families with incomes up to 200% of the federal poverty level. The Health Care Financing Administration Health Care Financing Administration, department in the U.S. agency of Health and Human Services responsible for the oversight of the Medicaid and Medicare benefit programs, including guidelines, payment, and coverage policies.
Health Care Financing Administration

HCFA, See Health Care Financing Administration.
), the federal agency that administers CHIP, reports that two million children were enrolled nationwide as of September 30, 1999.

According to according to
1. As stated or indicated by; on the authority of: according to historians.

2. In keeping with: according to instructions.

 the federal CHIP statute, a state may design its CHIP program in one of three ways: by expanding its Medicaid program, by creating or expanding a state-designed program not based on Medicaid or by using a combination of the two approaches. A 1999 review by The Alan Guttmacher Alan Frank Guttmacher (1898-1974) was an American physician.

He served as president of Planned Parenthood and vice-president of the American Eugenics Society, founded the Association for the Study of Abortion in 1964, was a member of the Association for Voluntary
 Institute (AGI (Artificial General Intelligence) A machine intelligence that resembles that of a human being. Considered impossible by many, most artificial intelligence (AI) research, projects and products deal with specific applications such as industrial robots, playing chess, ) of the initial state plans submitted to HCFA found that 21 states and the District of Columbia District of Columbia, federal district (2000 pop. 572,059, a 5.7% decrease in population since the 1990 census), 69 sq mi (179 sq km), on the east bank of the Potomac River, coextensive with the city of Washington, D.C. (the capital of the United States).  had opted to expand their Medicaid program, 16 states were developing an entirely separate program, and 13 states intended to take a combination approach.

In the states choosing to expand their Medicaid program, CHIP enrollees are regular Medicaid enrollees; as such, they are entitled to the full range of Medicaid-covered services, including routine gynecologic gynecologic /gy·ne·co·log·ic/ (gi?ne-) (jin?e-kah-loj´ik) pertaining to the female reproductive tract or to gynecology.  examinations, Pap tests, diagnosis and treatment of sexually transmitted diseases Sexually transmitted diseases

Infections that are acquired and transmitted by sexual contact. Although virtually any infection may be transmitted during intimate contact, the term sexually transmitted disease is restricted to conditions that are largely
 (STDs) as well as family planning family planning

Use of measures designed to regulate the number and spacing of children within a family, largely to curb population growth and ensure each family’s access to limited resources.
 services and supplies. (The federal Medicaid statute specifically mandates coverage of family planning services for "minors who can be considered to be sexually active.")

In contrast, the states choosing to design programs of their own have wide latitude in crafting a benefit package. The CHIP statute itself requires coverage of only such basic services basic services, frequently insurance companies split dental procedures into basic and major categories. Basic services usually consist of diagnostic, preventive, and routine restorative dental services.
 as physician and hospital care, laboratory and X-ray services, well-child care and immunizations. According to the AGI review, of the 29 approved state plans that had some state-designed component, 16 specifically indicated that family planning services and supplies would be covered, while most of the remaining plans indicated that the general category "prenatal care prenatal care,
n the health care provided the mother and fetus before childbirth.
 and pre-pregnancy family planning services" would be covered.

Teens' Reproductive Health Needs

Teens need a range of educational and medical services related to reproductive health. Half of all U.S. teens are sexually experienced. While sexual activity is rare among younger teens, it is common in the later teenage years; by age 19, over three-fourths of females and 85% of males have had intercourse. Yet, teens are less likely than older women to report consistent use of effective contraceptive methods. In addition, sexually active teens younger than 18 are less likely to use any method of contraception, compared with older women.

Contraceptive use is critical for sexually active teens to avoid unintended pregnancy and to protect themselves against STDs. A sexually active teenager who does not practice contraception has a 90% chance of becoming pregnant within one year. In fact, every year, some 900,000 American teens between the ages of 15 and 19 become pregnant, giving the United States one of the highest teenage pregnancy teenage pregnancy Adolescent pregnancy, teen pregnancy Social medicine Pregnancy by a ♀, age 13 to 19; TP is usually understood to occur in a ♀ who has not completed her core education–secondary school, has few or no marketable skills, is  rates in the developed world.

The United States also has among the highest teen STD (Subscriber Trunk Dialing) Long distance dialing outside of the U.S. that does not require operator intervention. STD prefix codes are required and billing is based on call units, which are a fixed amount of money in the currency of that country.  rates in the developed world. Each year, three million teens--about one in four sexually experienced teens--acquire an STD, which can compromise their ability to have children later in life or lead to life-threatening health problems, such as cancer or HIV HIV (Human Immunodeficiency Virus), either of two closely related retroviruses that invade T-helper lymphocytes and are responsible for AIDS. There are two types of HIV: HIV-1 and HIV-2. HIV-1 is responsible for the vast majority of AIDS in the United States.  infection. For example, recent studies indicate that up to 1030% of sexually active teenage women tested for STDs are infected with chlamydia chlamydia (kləmĭd`ēə), genus of microorganisms that cause a variety of diseases in humans and other animals. Psittacosis, or parrot fever, caused by the species Chlamydia psittaci, , which, if left untreated, can lead to pelvic inflammatory disease pelvic inflammatory disease (PID), infection of the female reproductive organs, usually resulting from infection with the bacteria that cause chlamydia or gonorrhea. , ectopic pregnancy ectopic pregnancy
 or extrauterine pregnancy

Condition in which a fertilized egg is imbedded outside the uterus (see fertilization). Early on, it may resemble a normal pregnancy, with hormonal changes, amenorrhea, and development of a placenta.
 and infertility. Additionally, teens have higher rates of gonorrhea gonorrhea (gŏnərē`ə), common infectious disease caused by a bacterium (Neisseria gonorrhoeae), involving chiefly the mucous membranes of the genitourinary tract.  than women older than 20, and some studies have found that up to 15% of sexually active teenage women are infected with human papillomavirus human papillomavirus (HPV), any of a family of more than 60 viruses that cause various growths, including plantar warts and genital warts, a sexually transmitted disease. Detectable warts can be or removed, usually by chemicals, freezing, or laser, but often recur.  (HPV HPV human papillomavirus.

human papilloma virus

Human papilloma virus (HPV) 
), many with a strain of the virus linked to cervical cancer Cervical Cancer Definition

Cervical cancer is a disease in which the cells of the cervix become abnormal and start to grow uncontrollably, forming tumors.

Nonetheless, there are some disturbing indications that teenagers may not always be getting the full range of reproductive health care services they need. According to a study in the July 1999 issue of Pediatrics, only half of all physicians reported that they provided any counseling or education in their encounters with adolescents; fewer than 3% reported providing counseling or education on STDs or HIV. According to the 1997 Commonwealth Fund Survey of the Health of Adolescent Girls, only 15% of adolescent boys and 26% of adolescent girls reported that their provider had discussed pregnancy prevention with them. Similarly, only 24% of boys and 28% of girls reported that their doctor had discussed how to prevent STDs or HIV. And a study in the December 15, 1999, issue of the Journal of the American Medical Association JAMA: The Journal of the American Medical Association is an international peer-reviewed general medical journal, published 48 times per year by the American Medical Association. JAMA is the most widely circulated medical journal in the world.  reported that adolescents who are sexually active are more likely than other teens to forgo important health care, such as an annual physical exam. The study found that 25% of sexually active teens had forgone care, compared with only 15% of teens who are not sexually active.

Care Guidelines Remarkably Consistent

For guidance in making important decisions about the coverage for adolescents in their CHIP program, state policymakers may look to several widely accepted guidelines of care for preventive services to teens that have been developed by major health organizations. The three most comprehensive efforts are Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, which was sponsored by the Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979
Health and Human Services, HHS
; Guidelines for Adolescent Preventive Services (GAPS), which was developed by the American Medical Association American Medical Association (AMA), professional physicians' organization (founded 1847). Its goals are to protect the interests of American physicians, advance public health, and support the growth of medical science. ; and Primary and Preventive Health Care for Female Adolescents, which was published by the American College of Obstetricians and Gynecologists The American College of Obstetricians and Gynecologists (ACOG) is a professional association of medical doctors specializing in obstetrics and gynecology in the United States. It has a membership of over 49,000[1] and represents 90 percent of U.S.  (ACOG ACOG American College of Obstetricians and Gynecologists.
ACOG American College of Obstetricians & Gynecologists
). These national guidelines strongly emphasize that comprehensive reproductive health services for teens, including both health guidance and medical care, are an integral component of preventive health services health services Managed care The benefits covered under a health contract  for this population. In fact, despite subtle differences, these recommendations, which are summarized below, are remarkably consistent (see chart).

* Routine, preventive service visits

Routine visits are the mainstay of comprehensive and coordinated preventive care Preventive care is a set of measures taken in advance of symptoms to prevent illness or injury. This type of care is best exemplified by routine physical examinations and immunizations. The emphasis is on preventing illnesses before they occur. See also
  • Public health
 for teens. Health Care for Female Adolescents recommends that the initial visit for health guidance, screening and preventive care take place between the ages of 13 and 15. This initial visit should be followed by annual preventive health visits. The American Medical Association's GAPS recommends that all teens between the ages of 11 and 21 receive annual, routine visits, including three complete physical examinations--one each during early (11-14), middle (15-17) and late (18-21) adolescence.

All three sets of guidelines stress the importance of integrating medical care with education and counseling on responsible sexual decision-making. Annual preventive visits that promote routine and predictable screening, counseling and intervention are vital to this integrated approach. Since participation in risky behaviors can begin at any age, regular visits provide the opportunity to identify teens who have recently initiated, or are considering engaging in, such behaviors. They also offer an opportunity to identify teens who have recently become sexually active and to provide them with information concerning unintended pregnancy and STD prevention.

The various guidelines recommend that all teens should be screened during routine, preventive visits to determine their sexual history and practices. A comprehensive sexual history can be used to identify risk and evaluate the need for services as well as additional counseling and education. GAPS recommends that sexually active teens be asked about "their use and motivation to use condoms and contraceptive methods, their sexual orientation sexual orientation
The direction of one's sexual interest toward members of the same, opposite, or both sexes, especially a direction seen to be dictated by physiologic rather than sociologic forces.
, the number of sexual partners they have had in the past six months, if they exchanged sex for money or drugs, and their history of prior pregnancy or STDs. Adolescents at risk for pregnancy, STDs (including HIV), or sexual exploitation should be counseled on how to reduce this risk." GAPS adds that both teens and their parents and other adult caregivers should receive guidance on the use of "tobacco products, alcohol and other drugs" in conjunction with sexual activity.

* Cancer screening

The guidelines all recommend that sexually active female teens receive a Pap test annually to screen for cervical cancer. In addition, GAPS and Health Care for Female Adolescents recommend that females 18 or older receive annual Pap tests, regardless of whether they are sexually active.

Bright Futures also recommends that instruction in breast and testicular self-examination Testicular Self-Examination Definition

A testicular self-examination (TSE) is the procedure by which a man checks the appearance and consistency of his testes.

Most testicular cancers are first noticed by the man himself.
 be a part of routine physical examinations; the other practice guidelines practice guidelines Medical practice A set of recommendations for Pt management that identifies a specific or range of range of management strategies. See Peer review organization, Practice standards. Cf 'Cookbook' medicine.  do not address the issue.

* STD/HIV screening

The various guidelines also recommend that all sexually active teens be screened for gonorrhea and chlamydia. Health Care for Female Adolescents and Bright Futures recommend that these tests be performed annually, while GAPS suggests that the frequency of the screening should depend on the individual's sexual history.

For teens at risk for HIV, the guidelines recommend that testing be confidential and that it occur only after the teen gives informed consent and in conjunction with pre-test and posttest post·test  
A test given after a lesson or a period of instruction to determine what the students have learned.

GAPS makes additional recommendations regarding follow-up for positive STD tests: Positive results should be followed by additional tests, as appropriate to make a definitive diagnosis, and a treatment plan should be instituted and the use of condoms encouraged.

* Health guidance on sexual development

The guidelines all recommend that as a part of routine health visits, teens receive health guidance--information, counseling and anticipatory guidance--about puberty and sexual development. In the context of health guidance on sexual development, Bright Futures suggests that health professionals ask young adolescents such questions as "Has anyone talked with you about what to expect as your body develops? Do you think you are developing pretty much like the rest of your friends? Have you started your period? Is it regular?" Health professionals can use the answers to these queries to provide information and counseling about sexual development appropriate to the individual patient.

Both Health Care for Female Adolescents and GAPS additionally recommend that parents or other adult caregivers be given periodic guidance regarding sexual development.

* Health guidance on responsible sexual behavior sexual behavior A person's sexual practices–ie, whether he/she engages in heterosexual or homosexual activity. See Sex life, Sexual life.  and decision-making The various guidelines recommend that all teens receive information and counseling--as part of routine, preventive service visits--about sexual decision-making, including information about abstinence, contraceptive methods, and STD transmission and prevention. According to all the major guidelines, teens should be given information on the importance of pregnancy and STD prevention, the role of abstinence as an effective way to prevent unintended pregnancy and STDs, ways to prevent HIV transmission and basic facts about protection from sexual exploitation. Adolescents should also be given counseling to reinforce responsible sexual behavior, both among those who are not currently sexually active and among those using birth control and condoms effectively.

Health Care for Female Adolescents specifically urges that teens be informed that the most effective protection against unintended pregnancy and STDs, other than abstinence, is a combination of latex condoms and hormonal methods of contraception. GAPS recommends that all adolescents should receive annual counseling on responsible sexual behaviors, including abstinence. "Latex condoms to prevent STDs, including HIV infection, and appropriate methods of birth control should be made available, as should instructions on how to use them effectively."

Health Care for Female Adolescents specifically recommends that teens be counseled about emergency contraception Emergency Contraception Definition

Emergency contraception or emergency birth control uses either emergency contraceptive pills (ECPs) or a Copper-T intrauterine device (IUD) to help prevent pregnancy following unprotected vaginal intercourse.

Bright Futures suggests that health professionals question teens about the information they have learned from their family, friends, school and other sources, and supplement that information in the course of responding to their specific questions, problems or concerns. Bright Futures also suggests that the handouts that health professionals give adolescents to review at home should include, among other things, statements such as "Recognize that sexual feelings sexual feelings A constellation of psychological sentiments that constitute desire for sexual satisfaction or release of sexual tension  are normal, but having sex should be a well-thought-out decision. Delay having sex until you are mature enough to assume responsibility for sexual relations sexual relations
1. Sexual intercourse.

2. Sexual activity between individuals.
. If you are sexually active, discuss contraceptive methods and STD prevention with the health professional and your partner. Learn about and practice safer sex."

The Critical Role of Confidentiality

While routine guidance and care may play a vital role in preventing myriad serious health and social consequences, teens face substantial barriers to accessing care, including, among other things, deep-seated concerns about confidentiality. These concerns may prevent teens from seeking care in a timely fashion, or at all. As a result, the various guidelines stress the importance of confidentiality as a basic underpinning of the relationship between teenage patients and their health care providers. For some longstanding patients, this can mean recasting an ongoing relationship that had included parents as equal partners. For newer patients, it may mean developing a relationship that is built from the start on the premise of confidentiality. According to the various guidelines, health professionals should establish office policies regarding confidential care for teenagers, and both teens and their parents should be informed of these policies from the outset. According to Health Care for Female Adolescents, confidentiality is frequently identified as a major obstacle to the delivery of care to teens. As a result, the guidelines recommend that rather than wait until a problem arises, physicians should initiate discussion of the subject with both the teenager and her parents, and at the same time stress the importance of open communication among all parties.

Serving Teens

Major Guidelines for Reproductive Health Services to Teenagers

Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents was developed by a special commission and a set of expert panels sponsored by the Health Resources and Services Administration The Health Resources and Services Administration (HRSA) is an agency within the United States Department of Health and Human Services whose goal is to improve access to health care for those without insurance.  and the Health Care Financing Administration of the Department of Health and Human Services. The second edition of the report, released in 2000, includes recommendations for preventive services from infancy through adolescence.

Guidelines for Adolescent Preventive Services (GAPS) was de the American Medical Association and released in 1992. GAPS was written with the assistance of a national scientific advisory board, which consisted of experts in medicine, social and behavioral science behavioral science
A scientific discipline, such as sociology, anthropology, or psychology, in which the actions and reactions of humans and animals are studied through observational and experimental methods.
 and health insurance.

Primary and Preventive Health Care for Female Adolescents by the American College of Obstetricians and Gynecologists (ACOG) in November 1999. The guidelines were developed under the direction of the Committee on Adolescent Health Care and were based in part on the American Medical Association's GAPS, which itself was developed with representation from ACOG.
                     Bright Futures:       Guidelines for
                     Guidelines for        Adolescent
                     Health                Preventive
                     Supervision of        Services
                     Infants, Children,    (GAPS)
                     and Adolescents
Developed by         Department of         American
                     Health and            Medical
                     Human Services        Association

Target Ages          11-21 years           11-21 years
Periodicity of       Annual                Annual

Suggested Components of Health Guidance

Sexual               X                     X
Breast/Testicular    X
Unintended           X                     X
STD Prevention       X                     X


Pap Test             Sexually active       Sexually active
                     teens, annually       or age 18,

STD Screening

Gonorrhea            Sexually active       Sexually active
                     teens, annually       teens *
Chlamydia            Sexually active       Sexually active
                     teens, annually       teens *
Syphilis             High-risk teens       High-risk
Human                Sexually active       Sexually active
Papillomavirus       teens, annually       teens *
HIV                  High-risk teens       High-risk

                     Primary and
                     Preventive Health
                     Care for Female
Developed by         American College
                     of Obstetricians
Target Ages          13-20 years
Periodicity of       Annual

Suggested Components of Health Guidance

Sexual               X
Unintended           X
STD Prevention       X


Pap Test             Sexually active
                     teens or age 18,

STD Screening

Gonorrhea            Sexually active
                     teens, annually
Chlamydia            Sexually active
                     teens, annually
Syphilis             High-risk teens
Human                Sexually active
Papillomavirus       teens, annually
HIV                  High-risk teens

* Frequency of screening depends on the individual's sexual practices
and history of STDs.

Note: High risk is generally defined as a history of STDs, multiple
sexual partners, having had a sexual partner who is at risk of STDs,
history of having sex in exchange for money or drugs. Most of the
standards also include living in a geographic area with a high
incidence of syphilis as a risk factor for syphilis and a history of
intravenous drug use or having had a blood transfusion before 1985 as
a risk factor for HIV.

back to text

Reprinted from an article by Rachel Benson Gold in the June 2000 issue of The Guttmacher Report on Public Policy. Research for the article was supported in part by a grant from the Annie E. Casey Foundation According to their website, "the Annie E. Casey Foundation has worked to build better futures for disadvantaged children and their families in the United States." The foundation is a regular contributor to public broadcasting, including National Public Radio. . The conclusions and opinions expressed, however, are those of the author and The Alan Guttmacher Institute.
COPYRIGHT 2000 Guttmacher Institute
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2000 Gale, Cengage Learning. All rights reserved.

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Title Annotation:State Children's Health Insurance Program
Publication:Adolescent Care Standards and State CHIP Efforts
Article Type:Topic Overview
Geographic Code:1USA
Date:Jun 1, 2000

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