Access to adolescent reproductive health services: financial and structural barriers to care - Viewpoint

Perspectives on Sexual and Reproductive Health, May-June, 2003 by Linda Hock-Long, Roberta Herceg-Baron, Amy M. Cassidy, Paul G. Whittaker

Since the early 1970s, adolescent pregnancy rates in the United States, the United Kingdom and other western European countries have dropped significantly, partly because of the availability of more effective contraceptive methods and increases in condom use. (1) Despite this progress, U.S. youth continue to be at greater risk for pregnancy and sexually transmitted diseases (STDs) than their British and other western European peers. Given these disparities, can experiences in other developed countries inform U.S. prevention efforts? We believe that they can, and the results of Stone and Ingham's investigation of when and why British youth seek sexual health services, on page 114 of this issue, provide an instructive starting point.

A country's approaches to prevention are rooted in an interplay of socioeconomic, political and cultural forces. Consequently, to examine the relevance of Stone and Ingham's findings and recommendations in the context of the United States, it is necessary first to review the ways in which these forces impact access to reproductive health care.

ACCESS TO SERVICES

According to a framework that has been used to assess the extent to which five industrialized countries--Canada, France, Sweden, the United Kingdom and the United States--respond to the sexual and reproductive health needs of their youth, one important factor is the accessibility of services and prescription contraceptives. (2) Evidence to date suggests that youth in the United States are much more likely to encounter barriers to access than are their peers in the United Kingdom and other western European countries. (3)

Stone and Ingham observe that over the past 10 years or so, the United Kingdom has seen an increase in initiatives to reduce barriers to sexual and reproductive health services for young people, and a decrease in adolescent pregnancy rates. Although methodological considerations preclude direct comparisons, their investigation supports the notion that the gap between sexual debut and initiation of reproductive health care is far shorter for British youth than for U.S. youth. In Stone and Ingham's sample, three-quarters of female participants aged 21 or younger who had not sought reproductive health care prior to first sex did so within six months of sexual initiation. By contrast, the 1995 National Survey of Family Growth found that the median interval between first sex and first visit for reproductive health care was 22 months for U.S. females younger than 25. (4)

Financial considerations may play a role in determining level of access to sexual and reproductive health services and prescription contraceptive methods. In the United States, adolescents' access depends upon the extent to which they have health insurance coverage (private or public), the ability to pay directly for services, or access to family planning programs funded by Title X (the only national program that offers free or low-cost care for individuals who are uninsured or underinsured and meet income eligibility guidelines). Moreover, because many prescription drug plans do not provide coverage for a full complement of contraceptives, some adolescents who obtain clinical services through the private sector cannot afford the most effective methods. UK and other western European youth, who are eligible for benefits through health insurance systems sponsored or mandated by the government, face fewer financial barriers to services and prescription contraceptives than U.S. youth.

Two types of structural factors also affect access to sexual and reproductive health services and prescription contraceptives: confidentiality of and consent for care, and the service environment. (5) A prominent confidentiality-related concern for many adolescents in the United States is fear of parental notification through provider communications or health benefits notices issued by private insurers. (6) This fear is due in part to confusion regarding current confidentiality statutes, which have been described as a "patchwork of federal, state, and case law." (7)

The U.S. Public Health Service Act contains confidentiality regulations designed to reduce barriers to Title X family planning services for youth who cannot discuss their sexual and reproductive health needs with their parents, and these regulations supersede state law. However, a great deal of variation exists in state laws governing confidentiality and consent for services not funded through Title X. All states and the District of Columbia allow minors to consent for testing and treatment for HIV and other STDs. (8) In contrast, only 27 states and the District of Columbia have laws or policies specifically enabling them to consent for contraception. (9)

Variations in state abortion laws add to the confusion regarding availability of confidential reproductive health care for adolescents. Twenty-three states have statutes requiring parental consent before a minor may obtain abortion, services, and 21 have statutes requiring parental notification; these totals include two states that have laws requiring both. The remaining eight states and the District of Columbia encourage, but do not require, parental involvement in minors' abortion decision. (10)