Insurance Status of Urban Detained Adolescents

Insurance Status of Urban Detained Adolescents

Journal of Correctional Health Care 00(0) I-ll ©The Author(s) 2012 Reprints and permission: sagepub.com/journalsPermissions.nav DOl: 10.1177/1078345812455629 http://jcx.sagepub.com

®SAGE Matthew C. Aalsma, PhD 1, Margaret J. Blythe, MD 1, Yan Tong, PhD 2 , Jaros law Harezlak, PhD 2 •3 , and Marc B. Rosenman, MD 4

Abstract The primary goal was to describe the health care coverage of detained youth_ An exploratory second goal was to describe the possible relationship between redetention and coverage_ Health care coverage status was abstracted from electronic detention center records for I ,614 adolescents in an urban detention center (October 2006 to December 2007)- The majority of detained youth reported having Medicaid coverage (66%); 18% had private insurance and 17% had no insurance_ Lack of insurance was more prevalent among older, male, and Hispanic youth_ A substantial minority of detained youth were uninsured or had inconsistent coverage over time_ While having insurance does not guarantee appropriate health care, lack of insurance is a barrier that should be addressed to facilitate coordination of medical and mental health care once the youth is released into the community_

Keywords adolescence, insurance, juvenile justice, detention

Approximately 2 million youth under the age of 18 are arrested annually, and on a given day nearly 100,000 youth are held in a detention or correctional facility in the United States (National Center on Addiction and Substance Abuse at Columbia University, 2004). Youth held in a detention or correctional facility suffer from high rates of acute and chronic physical and mental health problems (Clark & Gehshan, 2007), including asthma, respiratory infections, dental concerns, dermatologic conditions, genitourinary infections, substance overdose or withdrawal syndromes, and trauma (Anderson & Farrow, 1998; Feinstein et al., 1998; Forrest, Tambor, Riley, Ensminger, & Starfield, 2006; Hein et al., 1980; Morris et al., 1995). Additionally, antisocial behavior before age 15 is associated with

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Department of Pediatrics, Section of Adolescent Medicine, Indiana University School of Medicine, Indianapolis, IN, USA Department of Medicine, Division of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA 3 Department of Public Health, Indiana University School of Medicine, Indianapolis, IN, USA 4 Department of Pediatrics, Children's Health Services Research, Indiana University School of Medicine, and Regenstrief Institute, Indianapolis, IN, USA 2

Corresponding Author: Matthew C. Aalsma, PhD, Section of Adolescent Medicine, Indiana University School of Medicine, 410 W. I Oth. St., Suite 1001, Indianapolis, IN 46202, USA Email: [email protected]

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journal of Correctional Health Care 00(0)

adverse outcomes in adulthood, including death, mental illness, crime, poverty, and hospitalizations related to substance abuse (Samuelson, Hodgins, Larsson, Larm, & Tengstrom, 2010). Youth held in a detention or correctional facility are at particular risk for sexually transmitted infections, including HIV, associated with high-risk behaviors (Teplin et al., 2005). Moreover, youth held in a detention or correctional facility have high rates of untreated and/or undetected psychopathology (Grisso, Barnum, Fletcher, Cauffman, & Peuschold, 2001 ); up to 70% of youth in the juvenile justice system have behavioral health care needs (Shufelt & Cocozza, 2006; Skowyra & Powell, 2006). Among youth in a detention or correctional facility, specific rates were as follows: 3% (both sexes) had psychotic illness, 10% of males and 29% of females had major depression, 11% of males and 19% of females had attention-deficit/hyperactivity disorder, and 53% (both sexes) had conduct disorder (Fazel, Doll, & Langstrom, 2008). In sum, a large number of youth held in a detention or correctional facility have substantial needs that warrant medical and mental health attention (Golzari, Hunt, & Anoshiravani, 2006). Given the medical and mental health profile of delinquent youth, connection to health care upon community reentry is a fundamental necessity. For the most part, to access and use medical and mental health services it is necessary to have health insurance. Access to services is limited when insurance is lacking (Cassedy, Fairbrother, & Newacheck, 2008). Additionally, when time gaps occur in insurance coverage, health seeking is delayed, which is associated with poor health outcomes (Olson, Tang, & Newacheck, 2005; Satchell & Pati, 2005). Gaps in insurance coverage also result in increased use of emergency departments. In a study of emergency room use in 2000, 1.5 million adolescents used emergency departments in lieu of usual health care (Wilson & Klein, 2000). Publicly financed health care coverage for youth is primarily from Medicaid (the largest insurer of children's health in the United States) and the State Children's Health Insurance Program (American Academy of Pediatrics Committee on Child Health Financing, 2005, 2007). Although no previously published studies have documented health care coverage status among adolescents entering detention facilities, the American Academy of Pediatrics has emphasized the importance of insurance for youth held in a detention or correctional facility (American Academy of Pediatrics Committee on Adolescence, 2001 ). Therefore, to understand how best to meet the medical and mental health care needs of detained youth, our goal was to describe health care coverage among detained youth. An exploratory second goal was to describe the possible relationship between redetention and health care coverage. The percentages of youth with Medicaid, private insurance, or no insurance upon entering the detention center are described and are broken down by age, gender, and race. Also, health care coverage patterns among youth detained more than once were examined.

Method As part of a broader research project assessing mental and physical health care among detained youth, electronic juvenile court records from a detention center in Indianapolis, Indiana, were analyzed. Electronic records pertaining to all detention placements from October 2006 through December 2007 for 13- to 18-year-olds were reviewed for this study, and demographic information, detention stay dates, and insurance status were extracted from electronic files by a research assistant. The study was approved by the Indiana University-Purdue University Indianapolis institutional review board. When a youth is arrested for a crime, a determination is made ifthere is a need for a secure placement. The determination for detention is based on the possibility that the youth may fail to appear in court for subsequent hearings or is a danger to public safety and may engage in new crimes prior to adjudication of the first allegation (Mulvey & Iselin, 2008; Steinhart, 2006). Thus, youth in the detention center in Indianapolis are being detained on a pretrial basis. After a trial verdict, a youth


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is returned to the community, placed in a residential placement facility, or committed to a juvenile correctional facility.

Measures Health care coverage status. At entry into detention, the youth or her or his parent/parents were asked about health care coverage by detention center staff. This field, in some cases, included details such as the name of an insurance company or other entity; we collapsed these values into three categories: Medicaid, private, and uninsured. Detention stays. A youth could be detained on multiple occasions during the 15-month study period. The number of detention stays and number of days in detention were calculated across the study period. Demographic information. We extracted age, gender, and self-reported race/ethnicity (White, Black, Hispanic, or multiracial)-all of which had been recorded at the time of detention-from the juvenile justice information system. The few subjects whose race/ethnicity was not in these four categories were excluded.

Statistical Analysis We compared youth with and without missing health care coverage data and described the number of detentions and the demographics among the study cohort. Age (at the first detention during the study period), gender, and race among youth detained once versus among those detained more than once were compared using x2 tests (or Fisher's exact test if cell size is less than 5 in the contingency table). The dependence of health care coverage status (Medicaid, private, or uninsured) on the demographic covariates (age, gender, and race) was evaluated using a generalized logistic regression approach with uninsured as the reference category and Medicaid and private insurance as two additionallevels of the outcome variable. The generalized logistic regression estimates of the association between demographic covariates and health care coverage status were used to obtain odds ratios (ORs) of coverage status and the respective predictors. Continuity of health care coverage was explored among youth who were redetained during the study period. For this analysis, Medicaid and private insurance were collapsed into the same (any insurance) category in order to compare rates with which youth had any insurance consistently across multiple detentions, had no insurance across multiple detentions, or had inconsistent coverage (sometimes any, sometimes no insurance).

Results Of 2,975 detentions during the study period, 15% were missing health care coverage status data. Under the assumption that the missing data occur at random (i.e., the probation officers do not ask about or record health care coverage status differently based on a detained youth's age, race, or gender), the results and the ORs we report below are valid. While this assumption cannot be proven empirically, we did examine it, to the extent possible, by using logistic regression to model the dependence of missing health care coverage status on age, gender, and race. None of these covariates were significantly associated with missing health care coverage status. We excluded from further analyses the detention stays with missing health care coverage data, which left a study sample of 2,521 records collected from 1,614 youth, indicating that a substantial number were redetained (551 youth, 35% ofthe 1,614).


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Table I. Number of Detentions per Youth During the Study Period (N = I ,614 youth) Number of Youth (%)

Number of Detentions

I ,063 (65.9) 334 (20.7) 126 (7.8) 57 (3.5) 22(1.4) I 0 (0.6) 2 (0.1)

One Two Three Four Five Six Seven

Table 2. Description of the Sample

N Age (years)a 13b 14b 15b 16b 17b 18b Gender Femaleb Maleb Race/ ethnicity Blackb Hispanicb Multiracialb Whiteb

Total Sample,

Once Detained, N

Multiply Detained,

p of x2 Test Once vs. Multiply

N (%)

(%)

N (%)

Detained

1,614 I 5.98 60 178 348 403 401 224

( 1.3) (3.7) (11.0) (21.6) (25.0) (24.9) ( 13.9)

307 (19.0) I ,307 (81.0)

960 79 71 504

(59.4) (4.9) (4.4) (31.2)

I ,063 16.1 I 37 116 197 250 274 189

( 1.4) (3.5) (10.9) ( 18.5) (23.5) (25.8) (17.8)

551 I 5.73 23 62 I5 I I 53 127 35

( 1.2) (4.2) (I 1.3) (27.4) (27.8) (23.1 (6.4)