Investing In The Health And Well-Being Of Young Adults

Young adulthood – ages approximately 18 to 26 – is a critical time in life. What happens during these years has profound and long-lasting implications for young adults, and – because many are parents – for the next generation.  Healthy, productive, and skilled young adults are critical for the nation’s workforce, global competitiveness, public safety, and national security.

Although young adults are resilient and adaptable, they are surprisingly unhealthy, showing a worse health profile than both adolescents and adults in their late 20s and 30s. Recent national attention on young adults has focused primarily on enrolling them in health care insurance to offset the higher costs associated with care for older adults under the Affordable Care Act 2010 provisions – mistakenly implying that it is not in their own interest to have health insurance. Unfortunately, too little attention has been paid to young adults’ specific health needs and the transitions they face once they are in the health care delivery system.

The Institute of Medicine and National Research Council recently released a new report titled Investing in the Health and Well-Being of Young Adults, which reviews what is known about the health, safety, and well-being of young adults and offers recommendations for policy and research. It was prepared by a committee with expertise in multiple disciplines, including public health, health care, behavioral health, sociology, social services, human development, neuroscience, economics, business, occupational health, media, and communications. We served as chair and a member of the committee, respectively.

Differentiating Young Adults From Adolescents and Older Adults

Whereas many industries segment and sharply differentiate young adults as a unique target audience for marketing products and services, they are infrequently treated as a distinct population in health policy, program design, and research. Instead, they are often grouped with all adults or sometimes with adolescents. The committee concluded that young adults ages 18 to 26 should be consistently viewed as a distinct subpopulation in health policy, planning, programming, and research due to their particular needs, health risk profiles, and transitions from pediatric or adolescent health care environments.

Young adulthood is a critical developmental period during which key tasks in the transition to independent adulthood need to be accomplished, including taking responsibility for one’s own health. Health care services must address period-specific needs. The process of maturation is not suddenly completed when a young person turns 18. Cognitive, emotional, and psychosocial maturation continues well into the mid-20s.

Furthermore, the current generation of young adults is undergoing this development in an era of unprecedented velocity and scale of change. This turbulence is driven by global economic restructuring, advances in information and communication technologies, data generation and dissemination, urbanization, and adjustments in the labor market – all of which have caused the landscape of risk and opportunity to be radically altered. These changes are placing greater demands on young adults than previous generations have faced and provide less latitude for failure. Essentially, young adults who are not keeping up will have a harder time catching up.

Young Adults Are Surprisingly Unhealthy

While the transition into adulthood highlights the importance of taking responsibility for one’s health, the dominant pattern among many young adults is declining health. As adolescents age into their early and mid-20s, they are less likely to eat breakfast, exercise, and get regular physical and dental checkups, and more likely to eat fast food, contract sexually transmitted diseases, smoke cigarettes, use marijuana and other drugs, and binge drink. They also are at higher risk of motor vehicle crashes, suicides, and firearm-associated homicides. Furthermore, the current generation of young adults is at the leading edge of the obesity epidemic.

Poor health in young adulthood has important consequences for future health, employment success, health care costs, and national security. For example, 62,000 individuals who reported for military training between 2006 and 2011 failed their entrance physical because of their weight. Rapid technological changes, economic challenges, and a prolonged transition to adulthood appear to be contributing to the health problems of young adults by increasing their stress levels and sedentary habits while making them less likely to participate in work and family roles that tend to decrease risk taking.

Mental health among young adults is an area of grave concern. Early adulthood is a time of heightened psychological vulnerability and onset of serious mental health disorders, a problem compounded by failure to recognize illness or to seek treatment. Along with substance use, mental health disorders are the greatest source of disability among young adults in the United States. Nearly two-thirds of the burden of disability in young adults is associated with either mental health or substance use disorders, and by age 29, more than half of all individuals have experienced such a disorder.

Extending Health Care Coverage for Young Adults

The provisions in the Affordable Care Act to extend coverage for young adults are well-known. The law requires that employer plans providing coverage for dependent children extend that coverage up to the age of 26. The Health Insurance Tracking Survey of Young Adults found in 2013 that 19- to 25-year-olds on parental employer plans increased from 13.7 million to 15 million between November 2011 and March 2013, and that 7.8 million of these young adults who joined a parent’s plan would not have been eligible for coverage in the absence of the employer mandate. The ACA also impacts young adults through mechanisms shared with other age groups: health insurance for college students, Medicaid expansion, and insurance exchanges. Also notable is the ACA requirement that states provide Medicaid coverage up to the age of 26 for most individuals aging out of foster care.

Expanding coverage is important for young adults, but not sufficient by itself to improve young adults’ health and well-being. A recent study showed that even though young adults’ coverage increased following enactment of the ACA, the impact on their health status and the care they received were limited. “Even with insurance, it is still hard to access health care,” said one member of the young adult advisory group that worked with us throughout our study process. “It is so complicated, and you don’t really learn in school how to navigate it.”

In addition to ongoing efforts to extend coverage, the report calls for action in three areas: (1) improving the transition from pediatric to adult medical and behavioral health care, (2) enhancing preventive care for young adults, and (3) developing evidence-based practices.

1. Improving the Transition From Pediatric to Adult Medical and Behavioral Health Care

The transition from pediatric to adult health care — including both medical and behavioral health care — is associated with poor outcomes for young adults. Structural barriers, such as funding streams and eligibility requirements, as well as age limits set by health systems, impose artificial boundaries between the two systems. These barriers negatively impact the transition process by creating discontinuities in care and associated poor outcomes. Other challenges arise because of adult health care providers’ lack of familiarity with disease processes and developmental issues among young adults.

Transitions of care have long been identified as an important problem in health care. The ACA includes several provisions that impose penalties for poorly managed care transitions and offer financial incentives for improving transition care. Examples of these provisions include reduced payments for readmission rates that exceed particular targets and payment for transition care services in medical homes. State Medicaid agencies also can provide reimbursement for transition care that occurs in “health home” practices, which provide physical, behavioral, and long-term care services.

The transition to adult care is included in the National Committee for Quality Assurance’s 2014 Standards and Guidelines for NCQA’s Patient-Centered Medical Home (PCMH). Transition of care for youth with special health care needs also is included as a Healthy People 2020 indicator. With these few exceptions, however, the focus on measuring transitions generally has not included the transition between pediatric and adult systems.

Our committee proposes more thoroughly incorporating the pediatric-to-adult transition of care in the current movement to improve transitions. We propose that health care delivery systems and provider organizations serving young adults develop a process for the transition from pediatric to adult care. We also propose that health care delivery systems include metrics on this transition among their quality performance metrics. Since metrics for this transition do not yet exist, we suggest that the Agency for Healthcare Research and Quality develop them.

2. Enhancing Preventive Care for Young Adults

Young adulthood provides an important opportunity for prevention. Serious illnesses and disorders can be avoided or managed better if young adults are engaged in wellness practices and screened for early signs of untreated illness, and the risk-taking that is common during these years can impact lifelong functioning. Yet only one-third of young adults received any type of preventive counseling on important issues for this age group, such as smoking, alcohol use, and mental health, during a primary care visit during the past year. And there is no consolidated package of preventive medical, behavioral, and oral health guidelines specifically focused on the young adult population.

Because young adults’ burden of disease is different from that of older adults and because other issues, such as fertility, may be of greater concern for this age group, it is important to have evidence-based recommendations assessed specifically for efficacy with young adults.

Therefore, as a first step in improving preventive care for young adults, the report recommends that the U.S. Preventive Services Task Force develops a consolidated set of standardized evidence-based recommendations for clinical preventive services such as screenings, counseling services, and preventive medications specifically for young adults aged 18-26. Behavioral and oral health should be included in these recommendations. This would be in a similar model to the task force’s special efforts around children/adolescents and older adults.

3. Developing Evidence-Based Practices

With the exception of interventions for treating early psychosis, there are few behavioral health interventions developed specifically for young adults, and few interventions with demonstrated efficacy specifically in this age group. The efficacy of the behavioral health treatments specifically for young adults is largely undemonstrated, because typical clinical trials and research studies (e.g., studies of adults aged 18-55) are insufficient to establish efficacy in young adults.

Although pharmacological treatments should be as effective in young adults as in older adults, psychosocial treatments and interventions need to be explicitly tested in this age group. Because of the psychosocial nature of non-pharmacological interventions – including preventive interventions and psychotherapy – they can be influenced by many factors that are changing or less mature in young adults, such as responsibility-taking, response to authority figures, and changing roles within the family.

Therefore, the report recommends that the National Institutes of Health support research aimed at developing a set of evidence-based practices for medical and behavioral health care, including prevention, for young adults. This research should build on the existing and established evidence-based practices. In some cases, existing interventions may be found efficacious in young adults or may be modified for this population, while in other situations entirely new interventions may be needed.

Improving Health for Young Adults

The health, safety, and well-being of young adults require focused attention in public health programs and in the delivery of health care services. Despite the resilience of young adults, their vulnerability is great, and continued inattention to their needs and requirements will be costly in the long run.

Improving behavioral, physical, and emotional health for young adults will improve their safety and well-being as well as their educational and employment outcomes. Our nation needs an active, agile, and skilled workforce to compete globally – all the more so as baby boomers retire in increasing numbers over the coming decades.