Abstract

Excerpted From: Sabrina Singh, Don't Forget about Adolescence: How the Braidwood Litigation Can Shape Access to Mental Health Services and Adolescent Development, 50 American Journal of Law & Medicine 139 (2024) (73 Footnotes) (Full Document)

Adolescence, typically defined between the ages of 10 to 19 years old, is a tumultuous time in an individual's life. This time is filled with growing independence, as an adolescent starts to have more freedom to interact with the world around them and to make decisions that can shape their life. Additionally, this time is associated with an influx of hormonal and psychological changes within the body. These environmental and bodily changes during adolescence can strain an individual's mental health. Consequently, it is important for adolescents to develop strategies early on to effectively manage their mental well-being. Early development of these strategies builds a foundation that allows individuals to better address their mental health concerns both as adolescents and as adults.

Policies that foster adolescents' knowledge about their mental health and management strategies are becoming increasingly important in the United States in response to the nation-wide youth mental health crisis. This age group is currently facing events that create risks to their mental health such as: the COVID-19 pandemic, global conflicts, and national economic instability. These different events create a sense of uncertainty for those experiencing them, and is one force behind the adolescent mental health crisis. However, such events over the last several years are not the sole cause of this crisis, because mental health concerns such as anxiety and suicidal thoughts, were increasing for years before the COVID-19 pandemic. Pre-pandemic contributors to the mental health crisis included increased academic pressure in school and the presence of social media. The pandemic only amplified these mental health concerns as teens were isolated from their peers due to stay-at-home orders. Given the range of contributors to the crisis, it is important to craft solutions that help healthcare providers work with adolescents to manage their mental health.

Proposed approaches to addressing the youth mental health crisis include both investment in a national strategy and more narrow city-specific initiatives. One suggested measure is to routinely screen adolescents for mental health issues such as depression and anxiety during visits with their primary care physicians. The integration of mental health services, such as screenings, into primary care visits (can help to increase dialogue around mental health among primary care physicians, adolescents, and their parents. The U.S. Preventive Services Task Force (USPSTF) further bolstered efforts to provide these screenings to adolescents by recommending their usage in 2022. These screenings are affordable to adolescents and their families because the Affordable Care Act (ACA) includes a provision that requires no co-pays or deductibles for patients, otherwise known as cost-sharing. Unfortunately, the ongoing Braidwood case threatens the viability of these screenings to remain free to individuals who use private insurance. The potential of cost-sharing may have negative implications beyond increased financial costs, such as the under-utilization of vital services, changes to how the doctor-patient relationship is formed, and increased racial and ethnic healthcare disparities partially resulting from poor doctor-patient communication.

This Article examines how cost-sharing for adolescent preventive care may shape access to mental health screenings and adolescent development. Part I provides an overview of the doctor-patient communication landscape and examines barriers to effective communication. Part II analyzes how a decision for the plaintiffs can shape adolescent access to preventive care and threaten healthy adolescent development. Specifically, I employ two frameworks to understand how a judgment for the plaintiffs may impact doctors and patients. First, I use structuration theory, a sociology meta-theory that is utilized by communication scholars, to understand how structure (e.g., a decision stating the rules around cost-sharing for adolescent preventive care services) can constrain doctors' communication behaviors, thereby making them less likely to suggest mental health screenings to adolescents. Second, I use a conceptual framework of adolescent development to show how a lack of screenings can threaten the goals of healthy adolescent development. Part III explores how doctors, parents, and adolescents can work together to overcome the barriers that the potential Braidwood decision for the plaintiffs can have on mental health prevention services. Ultimately, while Braidwood may have implications for how healthcare interactions are organized, adolescents and those who care for them still have opportunities to exert agency in their healthcare interactions.

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Adolescence is both an exciting and terrifying time in an individual's life. Unfortunately, this time of development is being disrupted by a national mental health crisis that threatens adolescents' ability to grow up into adults who can weather the emotional storms of life. One potential solution is to provide preventive care screenings to adolescents to help them identify their mental health concerns and receive timely care. However, the ongoing Braidwood case threatens the accessibility of these screenings due to the potential reimposition of cost-sharing. Cost-sharing measures would reduce the likelihood of doctors administering mental health screeners, thereby reducing adolescents' access to preventive care, and negatively impacting their development. Ultimately, while efforts to mitigate the country's mental health crisis are being threatened by Braidwood, it is still vital to provide preventive screenings to adolescents at a low cost in order to help them get access to mental health treatment in a timely manner.