The gap is still here: Access to physical and mental health care for children and adolescents 15 years after the Affordable Care Act

Asthma

There have been significant improvements in the incidence and prevalence of childhood asthma in the United States over the past 20 years. In 2005, almost 9% of children in America were directly impacted by asthma (CDC.gov/Asthma, 2007) representing approximately 6.5 million children and adolescents. In 2024, the rate of childhood asthma has dropped to 6.5%, representing 4.675 million children (CDC.gov/asthma, 2024). This is a drastic reduction in this potentially deadly disorder, which also evidenced by a reduction in emergency room use for asthma treatment and care, as well as a reduction in fatalities associated with uncontrolled asthma (CDC.gov/asthma, 2023). Epidemiologically, these reductions are likely attributable to the ACA increasing access to insurance, and specifically disease modifying drugs and preventative treatments (American Lung Association, 2024).

Public health and policy initiatives have also made great strides in the reduction of pollution exposure for children and youth. These campaigns have included the EPA Clean School Bus program which reduced the exposure to exhaust fumes and emissions exposures on school busses and significantly reduced environmental triggers to asthma for school children (EPA.gov/cleanschoolbus, 2024). Other policy initiatives focused on indoor air pollution in schools and public places where children spend significant amounts of time and reductions in pollution and environmental triggers have been significantly reduced (Pate, C.A. & Zahran, H.S. 2024; American Lung Association, 2024). The drastic decrease in the incidence and prevalence rates for asthma during this timeframe evidences the fact that systemic change is possible for improving the health of our nation’s youth.

Teen pregnancy

Another significant public health change is related to the reduction in teenage pregnancy rates nationwide. Between 2007 and 2022, the rate of teen pregnancy in the United States declined by almost 60% (OASH, 2024). A decline in teen pregnancy rates was once an improbable idea. Yet, through systemic changes including comprehensive sexual health education, access to health care through the ACA, and access to long term birth control options such as birth control implants and IUDs, the reduction in teen pregnancy rates have been highly impacted by policy, practice and shifts in social norms.

The changes in pregnancy rates are not equal across demographics and indicate that there is still work to do to allow all teens the options necessary to take control of their sexual health choices (Tevendale et al., 2024). There has also been a shift in delaying first pregnancy across the board apart from teen pregnancy by (OASH, 2024). More recently, the attorney general in the state of Missouri sued to block mifepristone access (“abortion pill”) within the state over the declining rate of teenage pregnancy in the state among 15-19 year olds (Missouri Independent, 2024). The audacity of this argument shows that there are still wide strides that are necessary to continue to move societal perceptions and beliefs for the benefit of all youth nationwide.

Diabetes

In 2023, the rates of diabetes continue to rise with an increase of approximately 2% each year for Type 1 diabetes and 5% annual incidence increase for Type 2 diabetes (American Diabetes Association, 2024; Wagenknecht et al., 2023; NIDDK, 2023). Although the percentage with diabetes is 0.35% of the population of those under the age of 18, this represents roughly 350,000 children and youth. It is important to note that the rate of type 2 diabetes in 2023 sits around 49,000 children and adolescents, with peak diagnosis being at age 16, which is a 150% increase over the rate of type 2 diabetes two decades earlier in 2003 in the same population (Hotu et al., 2004).

With the significant increases in obesity among children and youth, it is of no surprise that the rates of diabetes are also climbing. Diabetes is a chronic health condition, and although Type 1 diabetes is caused by a failure of the pancreas and results in a lifelong reliance on insulin, Type 2 diabetes can sometimes be modified by lifestyle and other health changes to prevent the need for insulin. Type 2 diabetes and obesity are often seen comorbidly, with diet and exercise being the primary interventions offered by the medical establishment (Buttermore et al., 2021).

Obesity

In 2009, the rate of obesity in youth under the age of 18 was 16%. By 2020, the rate of overall obesity in the population under the age of 18 was reported at between 20-22.2% and an overall obesity rate for ages 2-19 was reported at 19.7% (CDC, 2021; Centers for Disease Control and Prevention, 2023). This means that in 2020, 15.56 million children and youth in the United States were impacted by obesity. In one decade as the rate increased from 16% to almost 20% for children and youth, this represents an additional 3.16 million meeting obesity criteria. This drastic rise in obesity among children and youth is especially alarming, considering the Healthy, Hunger-Free Kids Act of 2010 (USDA, 2010) and subsequent reauthorizations which was focused on improving nutrition standards and reducing childhood hunger. Additional policy initiatives post COVID have attempted to bolster access to free breakfast and lunch for all children at schools however the bills including The Universal School Meals Program Act of 2021, have not made it out of committee for a vote in congress (Congress, 2021). Although the federal government has not moved on this action, individual states have made the decision to ensure that all children have access to breakfast and lunch at school, but this is not a universal experience for children in the United States. We know that access to adequate nutrition is one necessary component to address obesity, but it is not enough to solve this epidemic alone. Risk factors for obesity include sedentary activity, genetics, environmental factors including limited access to safe places to play, and poverty (Drozdz et al., 2021). Multisystemic changes are needed to address the complex challenges of childhood obesity.

As medications related to the treatment of obesity and Type-2 diabetes are becoming more available, and getting approved for use in young people, access to these treatments needs to be addressed for children and youth as primary and secondary prevention treatments. Glucagon-like peptide-1 receptor agonists (GLP-1) such as semaglutide and liraglutide are currently approved by the FDA for the treatment of obesity, and there have been many studies looking at the use, safety and efficacy of these medications for the treatment of obesity and diabetes among children and adolescents (Weghuber, D. et al., 2023; Ryan, P.M. et al., 2021; Shenker & Shalitin, 2024). The extensive research including several meta-analyses indicates that GLP-1 medications can be safely used in those under the age of 18 for moderate reduction in weight, reduction in A1-C and reduction in blood-pressure. These medications were not on the global radar for treatment of obesity a decade ago, however, they raise new promise of long-term solutions for obesity treatment. Prior to these medications, diet and exercise was the only long-term treatment regularly prescribed, which research repeatedly showed inadequate for meaningful, long-term change (Atlantis, E., et al. 2006; Bennet, B. & Sothern, M.S. 2009; Obita, G. & Alkhatib, A., 2023; Bishop et al., 2023). Access to care for obesity and diabetes must include access to efficacious treatment modalities.

Suicidality

From 2007 to 2018 the rate of suicide among youth increased by almost 60%. Suicide remains an epidemic among youth in the United States, with a rate of 13.6 per 100,000 (CDC.gov/suicide, 2024). Suicide being the third leading cause of death among youth is a painful reality that too many families and communities must grapple with (YRBS, 2023). Suicide risk is associated with several factors including exposure to suicide. We know that when youth know other people who attempt or commit suicide, they are more likely to follow suit in similar situations and also are more likely to believe that suicide is an accepted societal outcome for a given situation (Clayton et al., 2023).

From a critical perspective of public health, suicide prevention needs more than awareness campaigns and memorials. Efforts for suicide prevention need to include comprehensive mental health screening, assessment and treatment options and opportunities, without stigma or shame associated with seeking care. This is a bold and difficult directive, that will require a cultural shift to ensure that those who need help can receive it. Until society agrees that mental health is as important as physical health, we will continue to have disparities in care seeking behaviors among the most vulnerable of our communities, and our youth deserve better.

Depression

The rates of depression among children and adolescents have increased dramatically over the past 15 years. Point prevalence rates for depression among adolescents hovered around 9% at the start of the ACA (NSDUH, 2024). In 2023 the rates of depression in this age group were reported at upwards of 20% of the population (YRBS, 2023). Although depression is considered an internalizing problem, the risks associated with depression are a public health issue. The increases in depression can be attributed to several factors that are challenging families across demographics and many of these factors have also been compounded by the impact of the pandemic. These factors include increasing academic pressure, economic uncertainty and social pressures associated with early and pervasive use of social media (Abrams, 2023). Public health initiatives including early and periodic mental health screenings are key for identifying mental health issues for young people, and schools are obvious locations for these initiatives to take place (Manning, 2009; Abrams, 2023). Systemic change is necessary and will likely require both policy and social initiatives to make strides towards reducing depression among young people. These initiatives must include realistic pathways towards independence and success, and include economic stability.

ADHD

As the most commonly diagnosed mental health disorder, attention deficit hyperactivity disorder (ADHD) is often associated with educational issues or disruptions based on a common misconception that ADHD is a learning disability or behavior issue (Manning, 2009; NSDUH, 2024). Prevalence rates have increased in part due to improved diagnostic approaches that recognize that ADHD presents differently for girls and that ADHD is not solely a disorder of childhood (Young et al., 2020). The rate of ADHD in this population is around 10% which represents roughly 7.34 million youth (CDC, 2021). Although it was previously thought that ADHD prevalence and issues decreased as children aged, current science shows that the challenges associated with ADHD only become more sophisticated (Young et al., 2020). Taking a systemic approach when assessing for and treating ADHD are imperative to supporting young people with this mental health challenge.

Violence

Violence continues to plague America’s youth in ways that were simply unimaginable to previous generations. School violence has not slowed down, and tactics behind it have only gotten more sophisticated. Although improvements in some areas have been seen in overall student victimization rates over the past decade, aggression, bullying and hate related issues have remained steady experiences for children and youth in schools (NCES, 2024). Although violence is not a physical or mental health issue, the experience of violence causes both and has devastated communities across the nation. School violence is an epidemic and our children deserve the efforts necessary to change this.

Impact on education

There have been many challenges in education over this time. The biggest challenges have occurred from the disruptions to education during the COVID-19 pandemic where economic disparities raged full force (NCES, 2024). The movement from in person to remote learning deepened disparities that already existed in underfunded districts and widened the achievement gap across demographics. Although post pandemic test scores are showing signs of recovery, the impact of early learning loss will likely not be fully evidenced for several decades (NAEP, 2024). Families who did not have access to technology or adequate supports were thrust into the role of facilitating remote learning without the tools necessary to be successful. According to the FCC (2024), 21% of all US households lacked a high-speed internet connection during 2020.

Families did their best in many cases to navigate the complexities of remote learning, but for children who live in poverty, these complexities were more like brick walls between the children and their education. School districts that did not already own individual devices for students did not have resources to send home for remote learning, and as the world shut down, the lead time for ordering such devices increased exponentially. Placing the burden of education on the family during the pandemic was problematic at best especially when we consider that 20% of adults (1 in 5 adults) read below a third-grade level (The Policy Circle, 2024).