For adolescents with SU and co-occurring conditions, this is a time of both deep concern and significant opportunities. Because of the complicated systemic and financial barriers discussed, too often patients and their families are forced to navigate separate systems of care, often both public and private, and to coordinate their own care because appropriate linkages between providers and organizations are lacking and insurance and financial support is limited or nonexistent. This can be especially challenging for patients with co-occurring disorders; not surprisingly, many are unable to access or follow through with recommended, evidence-based, treatment regimens. Many patients “fall through the cracks,” and treatment initiation, engagement, and retention rates in this population are notoriously low.76
Many of the obstacles to treatment access have deep roots in the organizational and financial fragmentation of our health care system, but recent policy changes hold great promise for reducing them. The significance of system differences (public versus private, carved-out versus integrated, block grant versus Medicaid) has often been underappreciated in clinical and services research to date, and we know little about the differences in approach to system change that they might entail.
The cost issues related to adolescent treatment are complex. For instance, what are the implications of not finding the same cost reductions after treatment found in adults?12
Do new payment mechanisms, such as P4P, affect adolescent treatment in the same way as adult treatment? On these questions, the adult literature is often not applicable, and future research must examine long-term health care costs of adolescent SU and dual treatment patients.
The privacy issues discussed continue to be major hurdles to providing integrated treatment. Reforms such as eliminating pre-existing conditions as insurance disqualifiers may help to improve access, and they will be important to study.
The field must also address access and quality of treatment for young adults; their needs and treatment issues often differ from those of adolescents and older adults. Sometimes young adults “age out” of their parents' insurance coverage at a time when they are beginning to experience SU, psychiatric, and medical problems, or when their adolescent problems have become chronic. Many have no access to college or employment health care coverage.77
Others purchase limited coverage such as high-deductible plans, betting that they will remain healthy. Yet this group is most at risk for behavioral health problems.
Epidemiologic evidence demonstrates the common chronology of SU, psychiatric, and medical problem development, and that addressing problems earlier improves outcomes. Research on SBIRT in primary care for adolescents lags behind that of adult research, although this population will benefit most from it. Policy opportunities exist for implementing such programs (through more flexible financing mechanisms, as we have discussed), but the field has done little research to guide innovation.
In critical clinical and policy areas, research has relied on the adult SU literature (and sometimes the psychiatric literature). Future research must also target all components of health care reform and parity, with particular attention to the complexities and unintended consequences discussed above. The changes in federal and state laws on parity and health care reform will affect adolescents' SU, psychiatric, and medical treatment in ways unique to each system, but they also bring extraordinary opportunities to improve integrated treatment across conditions. It is here that the variations across systems will be most crucial to understand, for researchers, policy makers, advocates, and clinicians alike.