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

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Major legislation and sweeping strides for addressing the affordability of health care in the United States with The Affordable Care Act (ACA) which was codified into law and signed by President Obama, opening the possibility that the unmet physical and mental health needs of America’s youth may be reduced through the availability and affordability of health insurance for everyone (Patient Protection and Affordable Care Act, 2010). Over the past 15 years, the health and mental health of children and adolescents in the United States have undergone notable changes, reflecting both progress and persistent challenges. While public health initiatives and policy advancements have improved access to care and contributed to reductions in asthma prevalence and teen pregnancy rates, other areas continue to demonstrate systemic challenges. The rising incidence of obesity, Type 2 diabetes, depression, suicidality and ADHD highlight the ongoing need for comprehensive health interventions at the public health level. Additionally, disparities in healthcare access, particularly among rural and low-income populations, remain significant barriers to the overall well-being of children and youth. The shortage of primary care providers, gaps in insurance coverage and the increasing burden on school-based health clinics further complicate care accessibility. This paper examines the evolving trends in child and adolescent health, emphasizing the critical role of policy, environmental changes and healthcare innovations in shaping outcomes. After almost 15 years of this call to action and implementation of the ACA we have made strides towards healthy outcomes for children and youth, evidencing that transformative, systemic change is not only possible, but necessary to ensure the well-being of future generations." } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/14-167", "name": "The gap is still here: Access to physical and mental health care for..." } } ] } Home Browse The gap is still here: Access to physical and mental health care for... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Manning A. The gap is still here: Access to physical and mental health care for children and adolescents 15 years after the Affordable Care Act [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :167 ( https://doi.org/10.12688/f1000research.159195.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Review The gap is still here: Access to physical and mental health care for children and adolescents 15 years after the Affordable Care Act [version 1; peer review: 1 approved with reservations] Amy Manning https://orcid.org/0000-0002-7544-543X Amy Manning https://orcid.org/0000-0002-7544-543X PUBLISHED 06 Feb 2025 Author details Author details Social Work, SUNY Buffalo State University, Buffalo, New York, 14222, USA Amy Manning Roles: Conceptualization, Data Curation, Formal Analysis, Resources, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract In 2009 a review of the state of child and adolescent physical and mental health care in the United States, appeared hopeful with the possibility of addressing the unmet health needs of our nation’s children in schools (Manning, 2009). Major legislation and sweeping strides for addressing the affordability of health care in the United States with The Affordable Care Act (ACA) which was codified into law and signed by President Obama, opening the possibility that the unmet physical and mental health needs of America’s youth may be reduced through the availability and affordability of health insurance for everyone (Patient Protection and Affordable Care Act, 2010). Over the past 15 years, the health and mental health of children and adolescents in the United States have undergone notable changes, reflecting both progress and persistent challenges. While public health initiatives and policy advancements have improved access to care and contributed to reductions in asthma prevalence and teen pregnancy rates, other areas continue to demonstrate systemic challenges. The rising incidence of obesity, Type 2 diabetes, depression, suicidality and ADHD highlight the ongoing need for comprehensive health interventions at the public health level. Additionally, disparities in healthcare access, particularly among rural and low-income populations, remain significant barriers to the overall well-being of children and youth. The shortage of primary care providers, gaps in insurance coverage and the increasing burden on school-based health clinics further complicate care accessibility. This paper examines the evolving trends in child and adolescent health, emphasizing the critical role of policy, environmental changes and healthcare innovations in shaping outcomes. After almost 15 years of this call to action and implementation of the ACA we have made strides towards healthy outcomes for children and youth, evidencing that transformative, systemic change is not only possible, but necessary to ensure the well-being of future generations. READ ALL READ LESS Keywords Mental health, physical health, Affordable Care Act, school based health clinics, obesity, depression, asthma, violence, suicide, diabetes, teen pregnancy Corresponding Author(s) Amy Manning ( [email protected] ) Close Corresponding author: Amy Manning Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Manning A. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Manning A. The gap is still here: Access to physical and mental health care for children and adolescents 15 years after the Affordable Care Act [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :167 ( https://doi.org/10.12688/f1000research.159195.1 ) First published: 06 Feb 2025, 14 :167 ( https://doi.org/10.12688/f1000research.159195.1 ) Latest published: 06 Feb 2025, 14 :167 ( https://doi.org/10.12688/f1000research.159195.1 ) Introduction To attempt to address this formative question, a review of the current state of health and mental health for America’s youth is in order. In 2009, the state of the health of our nation’s children was rather bleak. The rate of obesity, diabetes, asthma, teen pregnancy, STD’s, depression, ADHD, aggression, violence, suicide and overall healthcare needs were significant, and the availability of care was problematic at best, and impossible at worst ( Manning, 2009 ). Children and adolescents in rural communities fared the worst with regards to access to care due to the nature of the geographic barriers to access ( King et al., 2006 ). Urban youth, while having greater proximity to multiple providers, did not enjoy access due, in large part, to affordability and insurance barriers ( Jennings et al., 2000 ). The question persists, how far have we come? The state of child and adolescent health in the United States Over the past 15 years, the state of children’s physical and mental health has evidenced both positive changes and challenges. Public health, environmental and policy initiatives have improved some health outcomes across the nation in areas including asthma, and teenage pregnancy. Even with these improvements, the overall state of physical and mental health for children and youth continue to show systemic challenges in areas including obesity, diabetes, depression, ADHD, violence and suicidality. It is possible that some of the increases in incidence and prevalence rates are due to the accessibility of care brought about through insurance access through the ACA, however, the numbers still tell a story of tens of millions of children and youth with chronic physical and mental health issues and unmet health needs. 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 ). The state of insurance and primary care Healthcare has been a political, social and economic challenge since the foundation of the United States. As the industrial revolution took hold in the early 20 th century, the modern health insurance industry began in Dallas, Texas when teachers created a program to prepay Baylor University Hospital for the future use of medical services sparking the creation of Blue Cross and employer-based health insurance ( Social Security Administration, 1965 ). Fast forward a century, the children and youth of the United States, continue to be relatively voiceless in the fight for health care coverage and access. In 2023, roughly 4 million children and youth under the age of 18 were uninsured, up approximately a quarter of a million children from 2022 ( Georgetown, 2024 ). The rate of uninsured children and youth has been steadily increasing since the peak insured rate of 95.5% in 2016 when the greatest expansions of Medicaid and state-based Children’s Health Insurance Programs (CHIP) were completed. Insurance coverage for care is only part of the story of access to care. From a public health perspective, primary care continues to be the best practice for continuity of care, chronic disease management and preventative care ( Adehge, 2024 ). We know that people utilizing primary care physicians tend to have better health outcomes due in part to continuity with both access and care received, especially for those who have chronic health conditions ( DeVoe et al., 2011 ; Kim et al., 2012 ). Preventative service utilization to identify problems before symptoms arise also tend to be higher among those with primary care physicians championing the role of primary care in preventative health care ( Adehge, 2024 ; Spatz et al., 2010 ). The past decade has seen a drastic 40% increase in the number of children and youth without access to primary care or a medical home ( Jabbarpour et al., 2024 ). Translating this percentage into people, this represents close to ten million children and youth in the United States without a usual, or typical place to receive health care, and one out of every ten children not having a primary care doctor ( Theis, 2024 ). This statistic is staggering and likely to continue to rise as the availability of primary care physicians have been decreasing drastically, with underinvestment in primary physician training programs, and increased reporting and administrative burden being placed on primary physician practices by insurance companies ( Jabbarpour et al., 2024 ). This model for care and payment is inadequate for the scope of the healthcare needs for children and youth in America. Removing the gap School based health clinics continue to be a logical location for public health initiatives to take place. Funding these clinics through the ACA has not been proven to be adequate, similarly to how having coverage through the ACA does not equate to having access to care. School based health clinics need to be funded and accessible regardless of the insurance coverage of an individual student. Yet, they also need to be staffed by competent medical professionals, who are paid fairly for their work. The investment into primary care recruitment, training and education programs requires policy and funding initiatives ( Jabbarpour et al., 2024 ). In addition to increasing physical and actual access to care in locations that children and youth spend their time, we also need to focus on reducing the disparities that exist which serve as risk factors for negative health consequences. This includes addressing childhood poverty. During the pandemic, the United States achieved the lowest ever recorded childhood poverty rate which held through 2022 through the policies enacted with the American Rescue Plan Act ( Collyer et al., 2023 ). We know that when families have the financial resources to take care of the basic needs of their households, the burden of poverty is removed. This is evidenced by reductions in child welfare issues, improved access to nutrition and overall stability within the family. When families are stable, fed, and peaceful, physical and mental health needs are more likely to be addressed. As we have seen, transformative systemic change is not just possible, it is within our reach. The remarkable strides that have been made over the past 15 years in reducing asthma, teen pregnancy and childhood poverty show us that when we prioritize the health and welfare of our nation’s youth, policy can have a profound impact on real world outcomes. These successes are a testament to what can be achieved when decision makers are untied behind evidence-based strategies for health and wellbeing. We stand at a pivotal point where the future of our children demands bold action to combat the growing challenges of youth suicide, depression, obesity, diabetes, violence and ADHD. We must reimagine and strengthen our economic, educational and health policies and priorities. By investing in equitable access to health care, creating supportive educational environments and ensuring families have the economic stability they need to thrive, we can give every young person the foundation for a healthy future. Our youth deserve no less than our full commitment to their well-being and success. Data and software availability No data are associated with this article. References Abrams Z: Kids’ mental health is in crisis. Here’s what psychologists are doing to help. Monit. Psychol. 2023, January 1; 54 (1). Reference Source Adeghe EP: Integrating pediatric oral health into primary care: A public health strategy to combat oral diseases in children across the United States. Int. J. Multidiscip. Res. Update. 2024; 7 (01): 027–036. Publisher Full Text American Diabetes Association: About diabetes. American Diabetes Association; 2024. Retrieved October 12, 2024. Reference Source American Lung Association: Trends in lung disease. American Lung Association; 2024. 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Retrieved October 3, 2024. Reference Source Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 06 Feb 2025 ADD YOUR COMMENT Comment Author details Author details Social Work, SUNY Buffalo State University, Buffalo, New York, 14222, USA Amy Manning Roles: Conceptualization, Data Curation, Formal Analysis, Resources, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 06 Feb 2025, 14:167 https://doi.org/10.12688/f1000research.159195.1 Copyright © 2025 Manning A. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Manning A. The gap is still here: Access to physical and mental health care for children and adolescents 15 years after the Affordable Care Act [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :167 ( https://doi.org/10.12688/f1000research.159195.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 06 Feb 2025 Views 0 Cite How to cite this report: Wolf M. Reviewer Report For: The gap is still here: Access to physical and mental health care for children and adolescents 15 years after the Affordable Care Act [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :167 ( https://doi.org/10.5256/f1000research.174887.r365477 ) The direct URL for this report is: https://f1000research.com/articles/14-167/v1#referee-response-365477 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 17 Feb 2025 Molly Wolf , PennWest University, Edinboro, Pennsylvania, USA Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.174887.r365477 Reviewer Comments This is an important paper, and I enjoyed reading it. It is extremely well-written, and adds a great deal to the current knowledge base. I have specific comments below to improve this paper, but I highly recommend ... Continue reading READ ALL Reviewer Comments This is an important paper, and I enjoyed reading it. It is extremely well-written, and adds a great deal to the current knowledge base. I have specific comments below to improve this paper, but I highly recommend this paper for indexing after addressing the comments below, as this paper significantly adds to the literature. Specific Comments: First sentence of abstract currently reads “In 2009 a review of the state of child and adolescent physical and mental health care in the United States, appeared hopeful with the possibility of addressing the unmet health needs of our nation’s children in schools (Manning, 2009).” Please add a comma after 2009, but remove the comma after the word ‘States’. The second sentence needs revision because it is not understandable as written. First sentence of Introduction states: “To attempt to address this formative question”, but as it is the first sentence of the paper, no question has been asked yet. Please clarify. It is unclear why the author chose the particular areas of concern (i.e., asthma, teen pregnancy, etc.) as opposed to other areas of concern. Please clarify as to why these particular areas were chosen for this article. This sentence: “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.” Please cite this. For every issue until ADHD: actual numbers are discussed and shown in terms of increase or decrease in the issue since the ACA. For ADHD, only current rates are shown, not what it used to be before ACA. Same issue for Violence. Impact on education: A few issues here: 1) Does not support the overall mission of the paper, which is to address health disparities since the advent of ACA. (I think? If this isn’t the mission of the paper, then this too needs to be made clearer.) 2) This section appears to only concentrate on pandemic and post pandemic issues, which is only 4.5 years old, not the 15 year mark that the paper is striving for. 3) Later in the paper, the author makes a compelling argument for school-based health clinics, and this would tie in neatly to the educational issues addressed in this section, if the author can connect these two. General Strengths of the Paper: Relevance and Contribution: The study successfully highlights the importance of community engagement in health interventions, particularly within underserved populations. Clarity and Organization: The introduction and literature review sections provide a comprehensive background, clearly outlining the research objectives and situating the study within the broader field of public health. Policy Implications: The author provides some excellent ideas that are concrete ways to actually put forth public policy that would be helpful from a preventative perspective. General Areas for Improvement: Grammar and Sentence Structure: This article needs some proof-reading. Several passages contain unclear phrasing or simple grammatical errors. Additional Literature Support: Some recent studies on digital health outreach and social media-based community engagement are missing from the literature review as well as the recommendations for prevention towards the end of the article. Including these sources would enhance the study's contemporary relevance. Recommendation: [ ] Accept as is [X] Accept with minor revisions [ ] Accept with major revisions [ ] Reject Final Comments: This article makes an important contribution to understanding the role of community engagement in public health, and is a good addition to the scientific knowledge base on this subject. Is the topic of the review discussed comprehensively in the context of the current literature? Yes Are all factual statements correct and adequately supported by citations? Yes Is the review written in accessible language? Yes Are the conclusions drawn appropriate in the context of the current research literature? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Social Work I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Wolf M. Reviewer Report For: The gap is still here: Access to physical and mental health care for children and adolescents 15 years after the Affordable Care Act [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :167 ( https://doi.org/10.5256/f1000research.174887.r365477 ) The direct URL for this report is: https://f1000research.com/articles/14-167/v1#referee-response-365477 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 06 Feb 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 Version 1 06 Feb 25 read Molly Wolf , PennWest University, Edinboro, USA Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Wolf M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 17 Feb 2025 | for Version 1 Molly Wolf , PennWest University, Edinboro, Pennsylvania, USA 0 Views copyright © 2025 Wolf M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Comments This is an important paper, and I enjoyed reading it. It is extremely well-written, and adds a great deal to the current knowledge base. I have specific comments below to improve this paper, but I highly recommend this paper for indexing after addressing the comments below, as this paper significantly adds to the literature. Specific Comments: First sentence of abstract currently reads “In 2009 a review of the state of child and adolescent physical and mental health care in the United States, appeared hopeful with the possibility of addressing the unmet health needs of our nation’s children in schools (Manning, 2009).” Please add a comma after 2009, but remove the comma after the word ‘States’. The second sentence needs revision because it is not understandable as written. First sentence of Introduction states: “To attempt to address this formative question”, but as it is the first sentence of the paper, no question has been asked yet. Please clarify. It is unclear why the author chose the particular areas of concern (i.e., asthma, teen pregnancy, etc.) as opposed to other areas of concern. Please clarify as to why these particular areas were chosen for this article. This sentence: “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.” Please cite this. For every issue until ADHD: actual numbers are discussed and shown in terms of increase or decrease in the issue since the ACA. For ADHD, only current rates are shown, not what it used to be before ACA. Same issue for Violence. Impact on education: A few issues here: 1) Does not support the overall mission of the paper, which is to address health disparities since the advent of ACA. (I think? If this isn’t the mission of the paper, then this too needs to be made clearer.) 2) This section appears to only concentrate on pandemic and post pandemic issues, which is only 4.5 years old, not the 15 year mark that the paper is striving for. 3) Later in the paper, the author makes a compelling argument for school-based health clinics, and this would tie in neatly to the educational issues addressed in this section, if the author can connect these two. General Strengths of the Paper: Relevance and Contribution: The study successfully highlights the importance of community engagement in health interventions, particularly within underserved populations. Clarity and Organization: The introduction and literature review sections provide a comprehensive background, clearly outlining the research objectives and situating the study within the broader field of public health. Policy Implications: The author provides some excellent ideas that are concrete ways to actually put forth public policy that would be helpful from a preventative perspective. General Areas for Improvement: Grammar and Sentence Structure: This article needs some proof-reading. Several passages contain unclear phrasing or simple grammatical errors. Additional Literature Support: Some recent studies on digital health outreach and social media-based community engagement are missing from the literature review as well as the recommendations for prevention towards the end of the article. Including these sources would enhance the study's contemporary relevance. Recommendation: [ ] Accept as is [X] Accept with minor revisions [ ] Accept with major revisions [ ] Reject Final Comments: This article makes an important contribution to understanding the role of community engagement in public health, and is a good addition to the scientific knowledge base on this subject. Is the topic of the review discussed comprehensively in the context of the current literature? Yes Are all factual statements correct and adequately supported by citations? Yes Is the review written in accessible language? Yes Are the conclusions drawn appropriate in the context of the current research literature? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Social Work I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Wolf M. Peer Review Report For: The gap is still here: Access to physical and mental health care for children and adolescents 15 years after the Affordable Care Act [version 1; peer review: 1 approved with reservations] . 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