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By Anita Brakman, MS
Senior Director of Education, Research and Training
Physicians for Reproductive Health
New York City
Taylor Rose Ellsworth, MPH
Director, Education, Research and Training
Physicians for Reproductive Health
New York City
Melanie Gold, DO, DABMA, MQT, FAAP, FACOP
Medical Director, School-Based Health Centers
New York-Presbyterian Hospital
Columbia University Medical Center
New York City
The U.S. Department of Health and Human Services recently released a report highlighting the fact that 2.3 million young adults (ages 19-26) have gained health insurance through the provisions of the Affordable Care Act, allowing them to be added to their parents’ insurance policies.1 While access to affordable care is a huge gain, being on parents’ insurance creates opportunities for breaches of confidentiality, especially through billing practices such as explanations of benefits.
Access to confidential care can affect decisions to seek care, willingness to disclose behaviors, and the likelihood of returning for necessary follow-up. This is not a new concept — a 1997 study of high school students found that a group randomized to receive assurances of confidentiality were much more likely to disclose sexual behavior to healthcare providers than a group who had no such assurances. Almost half (47%) who were given assurances of confidentiality were willing to make disclosures compared to 39% of those who were not. Additionally, the group given assurances was more likely to indicate they would return for follow-up care (67% vs. 53%).2
Most examinations of young people’s need for confidential care have focused on those younger than 18 years of age, the group who are most likely to depend on parents or other adults for healthcare. The more recent landscape of young adults up to age 26 who are included on parents’ health coverage has prompted new research to examine the need for confidentiality among this wider age range. A new analysis of the National Survey of Family Growth 2013-2015 data has assessed specifically whether youth would forgo health services without access to confidential care, as well as how often young people are provided time alone with a medical provider. The findings confirm that confidentiality remains essential for those younger than 18 years of age, and also is important for older adolescents and young adults.3
In this study, authors found that 18% of respondents ages 15-17 and 9% those 18-25 would forgo services if one or more parents could find out about their health visit. The likelihood of forgoing care was more pronounced among those with private health insurance (22% would forgo) compared to those with Medicaid (12%), regardless of age. Those most at risk of forgoing care were those ages 15-17 who were not living with a parent; 29% of this population would skip healthcare visits without an assurance of confidentiality.3
The study also asked those ages 15-17 who reported at least one healthcare visit during the last 12 months if they had time alone with a healthcare provider. Overall, 45% of this group reported some alone time with a provider, but 51% of the oldest respondents (age 17) reported time alone with a provide. Time alone with a provider also was more common among girls who reported previous sexual intercourse; 50% of sexually active girls reported having alone time with a provider, compared to 41% of their peers who reported never having sex. This difference was not seen among boys. Another difference seen only among girls was by race; 58% of black girls reported having time alone with a provider compared to 43% of white girls.3 Unfortunately, the survey did not include details about the type of healthcare visit or data on transgender and gender-nonconforming youth.
It is important to note that despite the importance of confidential care, many young people have open communication with their parents and other trusted adults regarding their sexual health. In the recent study, 30% of those ages 15-17 reported discussing four or more sexual and reproductive health (SRH) topics with their parents, and 37% of the older group reported discussing these topics with parents before they reached age 18.3 This affirms earlier data from a 2005 study, in which 60% of minors reported parents knowing about their sexual activity.4
States vary widely on their requirements for parental involvement or consent in minors’ SRH care, and medical providers can use tools such as those available on the Guttmacher Institute web site to learn about their local policies. In every state, patients of all ages can receive confidential care at sites funded by Title X, the federal family planning program.
In addition to confidentiality being necessary for individuals to seek care, it is also developmentally appropriate to offer young people.5 Over the course of adolescence, individuals have increasing capacity to give informed consent, have a need to develop autonomy, and can benefit from the opportunity to take responsibility for their health. Professional organizations including the American Academy of Pediatrics, Society for Adolescent Health and Medicine, American Academy of Family Physicians, and American Congress of Obstetricians and Gynecologists all support confidential SRH services for adolescents.6,7
Considering the past and present research, it remains clear that access to confidential care is essential for young people’s health. Providers must understand local policy, work to integrate confidentiality into practice systems such as electronic health records and billing systems, and make sure to discuss confidentiality with patients and their parents or legal guardians.
Financial Disclosure: Consulting Editor Robert A. Hatcher, MD, MPH, Nurse Planner Melanie Deal, MS, WHNP-BC, FNP-BC, Author Rebecca Bowers, Author Taylor Rose Ellsworth, Author Anita Brakman, Executive Editor Shelly Morrow Mark, Copy Editor Savannah Zeches, and Editorial Group Manager Terrey L. Hatcher report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Melanie Gold (author) serves on the advisory board for Afaxys Inc. and is a consultant for Bayer.