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One of the most compelling arguments for telemedicine is its potential to increase health care access by making care more affordable for patients and families, including those affected by asthma. This goal is critically important in the United States, where the high cost of asthma care is associated with nonadherence to preventive care regimens and suboptimal health outcomes. In this clinical commentary review, we draw from the literature and our own research to identify opportunities for and challenges to leveraging telemedicine to reduce the financial burden of asthma care. Our interviews with 42 families affected by asthma during the COVID-19 pandemic suggest that under favorable circumstances, telemedicine can meaningfully reduce costs, including those related to transportation and missed work, while offering high-quality care. However, families also identified ways in which telemedicine can increase costs. For example, some reported reduced access to support services and material resources such as medication samples, which they relied on to manage costs. In this way, our findings underscore the need for careful care coordination and communication in telemedicine. We conclude by discussing the 4Rs, a structured communication approach designed to support cost conversations, increase care coordination, and help families reduce asthma care cost burden.

This cohort study examines patterns and out-of-pocket costs of instrument-based screening among children 12 to 36 months.

Families affected by asthma report difficulty adhering to care regimens because of high medication costs, coupled with increased cost sharing required by some insurance plans. To inform efforts to support adherence, we conducted a qualitative study to explore how families manage asthma care costs.We conducted phone interviews with commercially-insured, US adults (Our analysis identified four overarching strategies for managing asthma care costs. First, participants used prevention strategies to avoid costly acute care by minimizing exposure to asthma triggers and adhering strictly to preventive medication regimens. Second, participants used shopping strategies to reduce costs, including by comparing medication prices across pharmacies, using medication coupons or free samples, and switching to lower-cost medications. Third, budgeting strategies involved putting aside funds, including in tax-exempt health savings accounts, or taking on debt to pay for care. Finally, some participants sought to reduce costs by forgoing recommended care, including by skipping medication doses or replacing prescribed medications with alternative therapies.Commercially-insured families use a wide range of strategies to manage asthma care costs, with both positive and negative implications for adherence. Our typology of asthma cost management strategies can inform insurance redesign and other interventions to help families safely reduce costs and maximize adherence to recommended care.

Disenrollment from health plans purchased on Affordable Care Act (ACA) Marketplaces is frequent; little is known whether disenrollment from off-Marketplace plans is as common or about the experiences and consequences of disenrollment. Using longitudinal administrative data on 2017-2018 nongroup plan enrollment linked with survey data, we analyze plan disenrollment in one regional insurance carrier servicing three states. Overall, 71% of enrollees disenrolled from their 2017 plan. Disenrollment was associated with purchasing through an ACA Marketplace, the carrier making significant changes to an enrollee’s plan benefit design, being healthier, being younger, and paying a higher premium for their 2017 plan in 2018. Experiencing financial burden or poor access to preferred providers was not associated with disenrollment. Most disenrollees (93.2%) enrolled in other coverage, often at a lower premium, but lacked confidence that they could afford needed care. These results can inform policy to support enrollees through coverage transitions and foster stability in the nongroup market.

Political orientation can be a powerful motivator of certain health care decisions. This study examines how political orientation was associated with decisions to use the Affordable Care Act Market...

More than 20 percent of Affordable Care Act (ACA) exchange market (Marketplace) members insured by a large national insurer in 2015 and 2016 enrolled during a special enrollment period (SEP), defin...

Women of working age (ages 19–64) faced specific challenges in obtaining health insurance coverage and health care before the Affordable Care Act. Multiple factors contributed to women’s experienci...

Key Points Question Is medical care affordable among people in the Medicare program? Findings In a nationally representative survey of 13 171 Medicare enrollees that asked several questions about the affordability of their medical care, the overall reported prevalence of ever delaying care during 2017 owing to worries about cost was 11%; the prevalence of having problems paying medical bills was also 11%, and 16% of the respondents experienced 1 of these 2 concerns or both. Unaffordability of care was associated with lower incomes, worse health, and being younger than 65 years with long-term disability. Meaning The findings of this study suggest that the burden of medical care cost-sharing leads to care avoidance and financial strains among the most vulnerable patients despite insurance coverage through Medicare; equitable access to care may require targeted reforms aimed at reducing cost burden., Importance Cost-sharing requirements can discourage patients from seeking care and impose financial hardship. The Medicare program serves many older and disabled individuals with multimorbidity and limited resources, but little has been known about the affordability of care in this population. Objective To examine the affordability of medical care among Medicare enrollees, in terms of the prevalence of delaying medical care because of costs and having problems paying medical bills, and risk factors for these outcomes. Design, Setting, and Participants Cross-sectional analyses conducted from November 1, 2019, to October 15, 2021, used logistic regression to compare the probability of outcomes by demographic and health characteristics. Data were obtained from the 2017 nationally representative Medicare Current Beneficiary Survey (response rate, 61.7%), with respondents representing 53 million community-dwelling Medicare enrollees. Main Outcomes and Measures New questions about medical care affordability were included in the 2017 Medicare Current Beneficiary Survey: difficulty paying medical bills, ongoing medical debt, and contact by collection agencies. A companion survey question asked whether individuals had delayed seeking medical care because of worries about costs. Results Respondents included 10 974 adults aged 65 years or older and 2197 aged 18 to 64 years; 54.2% of all respondents were women. The weighted proportions of Medicare enrollees with annual incomes below $25 000K were 30.7% in the older population and 67.4% in the younger group. Self-reported prevalence of delaying care because of cost was 8.3% (95% CI, 7.4%-9.1%) among enrollees aged 65 years or older, 25.2% (95% CI, 21.8%-28.6%) among enrollees younger than 65 years, and 10.9% (95% CI, 9.9%-11.9%) overall. Similarly, 7.4% (95% CI, 6.6%-8.2%) of older enrollees had problems paying medical bills, compared with 29.8% (95% CI, 25.6%-34.1%) among those younger than 65 years and 10.8% (95% CI, 9.8%-11.9%) overall. Regarding specific payment problems, 7.9% (95% CI, 7.0%-8.9%) of enrollees overall experienced ongoing medical debt, contact by a collection agency, or both. In adjusted analyses, older adults with incomes $15 000 to $25 000 per year had odds of delaying care more than twice as high as those with incomes greater than $50 000 (odds ratio, 2.47; 95% CI, 1.82-3.39), and their odds of problems paying medical bills were more than 3 times as high (odds ratio, 3.37; 95% CI, 2.81-5.21). Older adults with 4 to 10 chronic conditions were more than twice as likely to have problems paying medical bills as those with 0 or 1 condition. Conclusions and Relevance The findings of this study suggest that unaffordability of medical care is common among Medicare enrollees, especially those with lower incomes, or worse health, or who qualify for Medicare based on disability. Policy reforms, such as caps on patient spending, are needed to reduce Medical cost burdens on the most vulnerable enrollees., This survey study examines the affordability of health care and prevalence of payment difficulties among Medicare enrollees.

This cohort study assesses cost-related experiences in non-group plans purchased on or off Marketplace and variation by Marketplace enrollment, decision support use, and other characteristics.

OBJECTIVES Preventive drug lists (PDLs) are a value-based insurance design intended to help high-deductible health plan (HDHP) members by covering preventive medications at lower or no cost before deductibles are met. Because little is known about members' experiences using this new tool, we sought to evaluate benefits and challenges of using PDLs to manage asthma costs. STUDY DESIGN Qualitative interview study. METHODS In 2018, we conducted telephone interviews with US adults (n = 22) who (1) were in HDHPs with PDLs and (2) had asthma and/or a child with asthma. We analyzed data using thematic content analysis. RESULTS Some members reported that PDLs provided financial benefit and facilitated adherence to preventive medications. Others experienced barriers to using PDLs. Notably, some PDLs did not include members' asthma medications or provided only modest cost coverage due to restrictions in underlying formulary structures. Members who were aware of having a PDL sometimes worked with their providers to switch to listed medications. However, many members were not aware of having a PDL. Finally, because PDLs did not cover nonmedication costs, some members still struggled to afford asthma care. CONCLUSIONS PDLs are a promising tool for helping families in HDHPs manage their medication costs and, in turn, their asthma. However, given current limitations in coverage, members must be aware of the benefit to seek out listed medications, and they may still struggle with the remaining cost sharing. Attention to implementation, including member outreach and education, is likely needed to realize the full potential of PDLs.

Introduction Women historically have had difficulty maintaining health insurance, obtaining preventive care, and affording care. The objectives of this study were to describe changes in insurance affordability, healthcare access, and preventive care for women of different income levels after implementation of the Affordable Care Act. Methods This was a difference-in-differences analysis of data about U.S. women aged 19–64years from the National Health Interview Survey. This study examined self-reported insurance affordability, access to health care, and preventive services. Changes before (2010–2013) and after (2014–2017) the Affordable Care Act insurance expansions were compared by income (≤138% federal poverty level vs≥400% federal poverty level). Multivariate difference-in-differences analyses adjusting for demographics were expressed as risk differences. Results The sample represented an estimated 41,106,929 women. After the Affordable Care Act, women with incomes ≤138% federal poverty level, compared with ≥400% federal poverty level, had less difficulty finding affordable insurance (adjusted difference-in-differences: –27.18, 95% CI= –36.37, –18.00); were more likely to have seen/talked to a doctor in 12 months (adjusted difference-in-differences: 3.08, 95% CI=1.29, 4.87), had blood pressure screening (adjusted difference-in-differences: 3.27, 95% CI=1.94, 4.60), cholesterol screening (adjusted difference-in-differences: 5.05, 95% CI=2.45, 7.64), and mammograms (adjusted difference-in-differences: 6.87, 95% CI=3.94, 9.79). Conclusions After implementation of the Affordable Care Act, women in all income groups, especially the lowest, reported greater affordability of coverage, access to health care, and receipt of preventive services. Efforts to alter the Affordable Care Act should consider the impact of policy changes on women's health and preventive care.

Importance High-deductible health plans (HDHPs) are increasingly common and associated with decreased medication use in some adult populations. How children are affected is less certain. Objective To examine the association between HDHP enrollment and asthma controller medication use and exacerbations. Design, Setting, and Participants For this longitudinal cohort study with a difference-in-differences design, data were obtained from a large, national, commercial (and Medicare Advantage) administrative claims database between January 1, 2002, and December 31, 2014. Children aged 4 to 17 years and adults aged 18 to 64 years with persistent asthma who switched from traditional plans to HDHPs or remained in traditional plans (control group) by employer choice during a 24-month period were identified. A coarsened exact matching technique was used to balance the groups on characteristics including employer and enrollee propensity to have HDHPs. In most HDHPs, asthma medications were exempt from the deductible and subject to copayments. Statistical analyses were conducted from August 13, 2019, to January 19, 2021. Exposure Employer-mandated HDHP transition. Main Outcomes and Measures Thirty-day fill rates and adherence (based on proportion of days covered [PDC]) were measured for asthma controller medications (inhaled corticosteroid [ICS], leukotriene inhibitors, and ICS long-acting β-agonists [ICS-LABAs]). Asthma exacerbations were measured by rates of oral corticosteroid bursts and asthma-related emergency department visits among controller medication users. Results The HDHP group included 7275 children (mean [SD] age, 10.8 [3.3] years; 4402 boys [60.5%]; and 5172 non-Hispanic White children [71.1%]) and 17 614 adults (mean [SD] age, 41.1 [13.4] years; 10 464 women [59.4%]; and 12 548 non-Hispanic White adults [71.2%]). The matched control group included 45 549 children and 114 141 adults. Compared with controls, children switching to HDHPs experienced significant absolute decreases in annual 30-day fills only for ICS-LABA medications (absolute change, −0.04; 95% CI, −0.07 to −0.01). Adults switching to HDHPs did not have significant reductions in 30-day fills for any controllers. There were no statistically significant differences in PDC, oral steroid bursts, or asthma-related emergency department visits for children or adults. For the 9.9% of HDHP enrollees with health savings account–eligible HDHPs that subjected medications to the deductible, there was a significant absolute decrease in PDC for ICS-LABA compared with controls (−4.8%; 95% CI, −7.7% to −1.9%). Conclusions and Relevance This cohort study found that in a population where medications were exempt from the deductible for most enrollees, HDHP enrollment was associated with minimal or no reductions in controller medication use for children and adults and no change in asthma exacerbations. These findings suggest a potential benefit from exempting asthma medications from the deductible in HDHPs.

BACKGROUND: Unaffordability of medications is a barrier to effective treatment. Cost-related nonadherence (CRN) is a crucial, widely used measure of medications access. OBJECTIVES: Our study examines the current national prevalence of and risk factors for CRN (e.g., not filling, skipping or reducing doses) and companion measures in the US Medicare population. RESEARCH DESIGN: Survey-weighted analyses included logistic regression and trends 2006–2016. SUBJECTS: Main analyses used the 2016 Medicare Current Beneficiary Survey. Our study sample of 12,625 represented 56 million community-dwelling beneficiaries. MEASURES: Additional outcome measures were spending less on other necessities in order to pay for medicines and use of drug cost reduction strategies such as requesting generics. RESULTS: In 2016, 34.5% of enrollees under 65 years with disability and 14.4% of those 65 years and older did not take their medications as prescribed due to high costs; 19.4% and 4.7%, respectively, experienced going without other essentials to pay for medicines. Near-poor older beneficiaries with incomes $15–25K had 50% higher odds of CRN (vs >$50K), but beneficiaries with incomes

* Abbreviations: ACA — : Affordable Care Act COVID-19 — : coronavirus disease ESI — : employer-sponsored insurance FPL — : federal poverty level In addition to the devastating health effects of the coronavirus disease (COVID-19) pandemic, the United States is experiencing the highest rates of unemployment since the Great Depression.1 One important and overlooked consequence of unemployment is the loss of employer-sponsored insurance (ESI) coverage for children whose parents lose their jobs. It is estimated 27 million US adults will become uninsured because of unemployment and lose ESI during the pandemic.2 During the pandemic, >4 out of 10 parents with children

Asthma is the most common pediatric chronic condition, with substantial morbidity, health care utilization, and costs. Enrollment has increased in high‐deductible health plans (HDHPs) that require families to assume greater responsibility for out‐of‐pocket (OOP) costs for asthma and other family health care needs, creating potential barriers to use of recommended asthma controller medications. Data are limited on children in HDHPs. We sought to examine changes in asthma controller medication use, exacerbations, and OOP costs for children with asthma enrolling in HDHPs and whether this varies for children in families with multiple competing health care needs. We measured OOP costs for children’s asthma care and for care for all family members in the same insurance plan, and children’s rates of 30‐day fills for asthma controller medications and exacerbations (measured by oral steroid bursts). We controlled for the number of chronic conditions among all family members, defining high illness burden as presence of ≥ 4 chronic conditions. We used a difference‐in‐differences design with models controlling for individual and employer‐level characteristics, and tested for effect modification by family illness burden using a three‐way interaction. We identified children aged 4‐17 years with persistent asthma with employer coverage in a large commercial and Medicare Advantage claims database between 2002 and 2014. We selected children with 12 months of enrollment in a plan with low or no deductible (“traditional plan”) before either switching to a HDHP or staying in the traditional plan (controls) for another 12 months. The sample included only employers offering a single deductible level. The sample included 4708 children who switched to HDHPs and 47,414 who remained in traditional plans. Children switching to HDHPs had higher OOP costs for asthma care than controls (difference‐in‐differences (DiD) $21; 95% confidence interval (CI) $14‐$28), a relative increase of 21.5% (13.5%‐29.4%). Their families had greater OOP spending (DiD $605; 95% CI $505‐$704), a relative increase of 26.8% (21.8%‐31.8%). Children in HDHPs had a relative decrease in 30‐day controller medication fills (−7.4%, 95% CI −12.0% to −2.8%) but no relative difference in exacerbations (1.3%, 95% CI −10.5% to 13.2%). There was no evidence of effect modification by family illness burden. This study found increases in OOP asthma costs for children in HDHPs and lower rates of controller medication use, but no differences in asthma exacerbations. Families experienced an increase in total OOP costs in HDHPs, although this may have been offset by lower premiums. The lack of difference in the impact of HDHP enrollment on children’s controller use in families with high illness burden suggests these families are not trading off OOP spending on children’s asthma care for OOP spending on other care. Although families face increased OOP costs in HDHPs for children’s asthma and other health care, the impact on asthma medication use and exacerbations may be moderated by the fact that medications were subject to copayments rather than the deductible in most plans in our study. Value‐based insurance designs that exempt important pediatric health services from the deductible may help reduce adverse outcomes in HDHPs. Patient‐Centered Outcomes Research Institute.

Women of working age (ages 19-64) faced specific challenges in obtaining health insurance coverage and health care before the Affordable Care Act. Multiple factors contributed to women's experiencing uninsurance, underinsurance, and increased financial burdens related to obtaining health care. This literature review summarizes evidence on the law's effects on women's health care and health and finds improvements in overall coverage, access to health care, affordability, preventive care use, mental health care, use of contraceptives, and perinatal outcomes. Despite major progress after the Affordable Care Act's implementation, barriers to coverage, access, and affordability remain, and serious threats to women's health still exist. Highlighting the law's effects on women's health is critical for informing future policies directed toward the continuing improvement of women's health care and health.

Background Out-of-pocket (OOP) health care costs can cause financial burden and deferred care for many Americans. Little is known about OOP spending for asthma-related care among the commercially insured. Objectives To analyze OOP spending for asthma-related care overall, across types of care, and by income. Methods Using enrollment, claims, and geocoded census tract data on income from a large US commercial health plan from 2004 to 2016, we measured inflation-adjusted OOP spending for individuals with asthma ages 4 to 64 years (n = 1,986,769). We estimated annual asthma-related OOP spending over time, and average total, asthma-related, asthma type of care, and asthma medication spending by income. We measured trends in median OOP cost per medication. Linear regression models were adjusted for patient covariates and deductible level. Results Asthma-related OOP spending decreased over time both for patients enrolled in high-deductible health plans and for those in traditional plans. High-deductible plan enrollment increased from 7% to 54%. Compared with patients living in high-income areas, patients in the lowest-income areas had similar annual total and asthma-related OOP spending, but spent 30% less on controller medications and a higher proportion of their asthma-related OOP spending on inpatient and emergency care (10% vs 3%; P Conclusions Patients with asthma living in the lowest-income areas have greater cost burden, lower spending on controller medications, and greater spending on high-acuity care than higher-income counterparts.

RESEARCH OBJECTIVE: Patient cost‐sharing has been increasing over the past two decades, in particular due to high‐deductible health plans (HDHP). Asthma is a very common, serious, chronic disease in the United States. We analyzed a large, national sample of asthma patients to provide new evidence on OOP spending overall, across types of asthma care, and variation by patient income. STUDY DESIGN: We used 11 years (2004‐2014) of enrollment, claims, and geocoded census tract data on income. Annual OOP costs were measured as the sum of actual patient‐paid deductible, coinsurance and copayments on all medical care; spending was adjusted to 2014 dollars using the Medical CPI. Annual asthma OOP spending included OOP payments for asthma services (ie, asthma medications, office and emergency department (ED) visits, and hospitalizations with ICD‐9 codes for asthma, spacers for inhalers, asthma nebulizers). Patient income was measured using the census tract income associated with the patient’s address, and then, patients were categorized into income quintiles based on the distribution of household income across the United States (eg, not within sample). We report the association of OOP spending with patient income based on linear regression models controlling for patient age, sex, state, morbidity and asthma severity (using the Johns Hopkins ACG system), and year; models were stratified by annual HDHP enrollment. POPULATION STUDIED: All patients ages 4‐64 years with asthma (defined as having an asthma ICD‐9 diagnosis code for an outpatient or ED visit or hospitalization) in a large, national Commercial and Medicare Advantage claims database (n = 2 018 178). PRINCIPAL FINDINGS: More patients in the lowest‐income quintile had a HDHP. Within plan type, levels of spending associated with income quintiles were similar but represented a significantly larger proportion of income for the lowest‐income quintile (Table). CONCLUSIONS: Because patients spent similar amounts of OOP for asthma care, the lowest‐income quintile patients experienced greater cost burden. The majority of OOP asthma spending was on asthma medications, but lowest‐income quintile patients had greater spending on high acuity care than those in higher income quintiles. IMPLICATIONS FOR POLICY OR PRACTICE: Efforts should be made to understand whether these differences in cost burden are associated with cost‐related underuse of medications or other adverse outcomes to inform policy and insurance benefit design. PRIMARY FUNDING SOURCE: Patient‐Centered Outcomes Research Institute.

RESEARCH OBJECTIVE: Older adults and disabled individuals in Medicare often have limited financial resources and high levels of health care needs. When out‐of‐pocket costs are not affordable, treatment may be delayed or forgone, potentially leading to worse health outcomes. We examined newly available survey data to produce the first national prevalence estimates of problems paying medical bills and delaying care due to costs among Medicare enrollees. STUDY DESIGN: The Medicare Current Beneficiary Survey (MCBS) has enhanced the measurement of health care affordability with new questionnaire items. These include whether enrollees experienced problems paying or were unable to pay any medical bills in the past year, and, if so, whether they currently have medical bills that are being paid off over time and whether they have been contacted by a collection agency in the last year due to problems paying. A separate MCBS question asks whether enrollees have delayed seeking medical care in the past year because of cost worries. Our survey‐weighted analyses estimated the prevalence of payment problems and cost‐related delays among the overall Medicare population and groups defined by demographic and health‐related factors. We further tested predictors using multivariate logistic regression. POPULATION STUDIED: We included community‐dwelling participants in the nationally representative 2017 MCBS: 10,974 older adults aged 65+ years and 2197 adults aged 18‐64 years with long‐term disability status, together representing 53.0 million Medicare enrollees. PRINCIPAL FINDINGS: Overall, the prevalence of problems paying medical bills was 7.4% among older enrollees and 29.8% among disabled enrollees. Among seniors who had problems paying, 48.2% were paying off bills over time, and 44.3% had been contacted by a collection agency; these proportions were higher for disabled individuals (50.5% and 62.2%, respectively). Delayed care due to costs was similarly common (8.3% among those ≥65, 25.2% among

Preventive drug lists (PDLs) are a value-based insurance design intended to help high-deductible health plan (HDHP) members by covering preventive medications at lower or no cost before deductibles are met. Because little is known about members' experiences using this new tool, we sought to evaluate benefits and challenges of using PDLs to manage asthma costs.Qualitative interview study.In 2018, we conducted telephone interviews with US adults (n = 22) who (1) were in HDHPs with PDLs and (2) had asthma and/or a child with asthma. We analyzed data using thematic content analysis.Some members reported that PDLs provided financial benefit and facilitated adherence to preventive medications. Others experienced barriers to using PDLs. Notably, some PDLs did not include members' asthma medications or provided only modest cost coverage due to restrictions in underlying formulary structures. Members who were aware of having a PDL sometimes worked with their providers to switch to listed medications. However, many members were not aware of having a PDL. Finally, because PDLs did not cover nonmedication costs, some members still struggled to afford asthma care.PDLs are a promising tool for helping families in HDHPs manage their medication costs and, in turn, their asthma. However, given current limitations in coverage, members must be aware of the benefit to seek out listed medications, and they may still struggle with the remaining cost sharing. Attention to implementation, including member outreach and education, is likely needed to realize the full potential of PDLs.

The health insurance Marketplaces established by the Affordable Care Act include features designed to simplify the process of choosing a health plan in the individual, or nongroup, insurance market. While most individual health insurance enrollees purchase plans through the federal and state-based Marketplaces, millions also purchase plans directly from an insurance carrier (off Marketplace). This study was a descriptive comparison of the decision-making processes and shopping experiences of consumers in two states who purchased a health insurance plan from the same large insurer in 2017, either through the federal Marketplaces or off Marketplace. In a survey, those who selected plans through the Marketplaces reported less difficulty finding the best or most affordable plan than did those enrolling off Marketplace. Respondents in families with chronic health conditions who enrolled through the Marketplaces reported better overall experiences than those who enrolled off Marketplace. Respondents with low health insurance literacy reported poor experiences in enrolling both through the Marketplaces and off Marketplace. Access to consumer assistance in the individual health insurance market should target off-Marketplace populations as well as all populations with low health insurance literacy.

Objective To examine changes in children's albuterol use and out-of-pocket (OOP) costs in response to increased copayments after the Food and Drug Administration banned inhalers with chlorofluorocarbon (CFC) propellants. Setting Four health maintenance organizations (HMOs), two that increased copayments for albuterol inhalers that went from generic CFC-containing to branded CFC-free versions, and two that retained generic copayments for CFC-free inhalers (controls). We included children with asthma aged 4–17 years with commercial coverage from 2007 to 2010. Design Interrupted time series with comparison series. Data We obtained enrollee and plan characteristics from enrollment files, and utilization data from pharmacy and medical claims; OOP expenditures were extracted from pharmacy claims for two HMOs with cost data available. Findings There were no significant differences in albuterol use between the group with increased cost-sharing and controls with respect to changes after the policy change. There was a postpolicy increase of $6.11 OOP per month per child using albuterol among those with increased cost-sharing versus $0.36 in controls; the difference between groups was significant (p

Background Underuse of controller medicines among children with asthma remains widespread despite national guidelines. Objectives To (1) assess provider prescribing patterns for asthma controller medications; (2) assess how frequently parents' reports of their child's asthma controller medicine use were mismatched with their provider's recommendations; and (3) evaluate parent attitudes and demographic characteristics associated with these mismatches. Methods In this cross-sectional study, we conducted linked surveys of parents and providers of children with probable persistent asthma in a Medicaid program and 4 commercial health plans in 2011. Probable persistent asthma was defined as a diagnosis of asthma and 1 or more controller medication dispensing. Results This study included 740 children (mean age, 8.6 years). Providers for 50% of the children reported prescribing controller medications for daily year-round use, 41% for daily use during active asthma months, and 9% for intermittent use for relief. Among parents, 72% knew which class of controller medication the provider prescribed and 49% knew the administration frequency and the medication class. Parents were less likely to report the same controller medication type as the provider, irrespective of dose and frequency, if they were Latino (odds ratio [OR], 0.23; CI, 0.057-0.90), had a household smoker (OR, 2.87; CI, 0.42-19.6), or believed the controller medicine was not helping (OR, 0.15; CI, 0.048-0.45). Conclusions Mismatches between parent reports and providers intentions regarding how the child was supposed to use inhaled steroids occurred for half of the children. Efforts should focus on ways to reduce mismatches between parent and provider intentions regarding controller medication use.

Importance The Affordable Care Act (ACA) sought to improve access and affordability of health insurance. Although most ACA policies targeted childless adults, the extent to which these policies also impacted families with children remains unclear. Objective To examine changes in health care–related financial burden for US families with children before and after the ACA was implemented based on income eligibility for ACA policies. Design, Setting, and Participants Data used for this cohort study were obtained from the 2000-2017 Medical Expenditure Panel Survey, a nationally representative, population-based survey. Multivariable regression with a difference-in-differences estimator was used to examine changes in family financial burden before and after ACA implementation according to income-based ACA eligibility groups (≤138% [lowest-income], 139%-250% [low-income], 251%-400% [middle-income], and >400% [high-income] federal poverty level). The cohort included 92 165 families with 1 or more children (age ≤18 years) and 1 or more adult parents/guardians. Exposures Income-based eligibility groups during post-ACA years (calendar years 2014-2017) vs pre-ACA years (calendar years 2000-2013). Main Outcomes and Measures Family annual out-of-pocket (OOP) health care and premium cost burden relative to income. High OOP burden was determined based on a previously validated algorithm with relative cost thresholds that vary across incomes, and extreme OOP burden was defined as costs exceeding 10% of income. Premiums exceeding 9.5% of income were classified as burdensome and premiums relative to median household income defined an unaffordability index. Results Compared with high-income families who experienced a lesser change post-ACA implementation (high OOP burden, 1.1% pre-ACA vs 0.9% post-ACA), the lowest-income families saw the greatest reduction in high OOP burden (35.6% pre-ACA vs 23.7% post-ACA; difference-in-differences: −11.4%; 95% CI, −13.2% to −9.5%) followed by low-income families (24.6% pre-ACA vs 17.3% post-ACA, difference-in-differences: −6.8%; 95% CI, −8.7% to −4.9%) and middle-income families (6.1% pre-ACA vs 4.6% post-ACA, difference-in-differences: −1.2%; 95% CI, −2.3% to −0.01%). Although premiums rose for all groups, premium unaffordability was the least exacerbated for the lowest-, low-, and middle-income families compared with higher-income families. Conclusions and Relevance The findings of this study suggest that low- and middle-income families with children who were eligible for ACA Medicaid expansions and Marketplace subsidies experienced greater reductions in health care–related financial burden after the ACA was implemented compared with families with higher incomes. However, despite ACA policies, many low- and middle-income families with children appear to continue to face considerable financial burden from premiums and OOP costs.

Objective Patient navigators (PNs) may represent a cost-effective strategy to improve transitional care and reduce hospital readmissions. We evaluated the impact of a PN intervention on health system costs in the 180 days after discharge for high-risk patients in a safety-net system. Data Source/Setting Primary and secondary data from an academic safety-net health system. Study Design We compared per-patient utilization and costs, overall and by age, for high-risk, medical service patients randomized to the PN intervention relative to usual care between October 2011 and April 2013. Intervention patients received hospital visits and telephone outreach from PNs for 30 days after every qualifying discharge. Data Collection/Extraction Methods We used administrative and electronic encounter data, and a survey of nurses; costs were imputed from the Medicare fee schedule. Principal Findings Total costs per patient over the 180 days postindex discharge for those aged ≥60 years were significantly lower for PN patients compared to controls ($5,676 vs. $7,640, p = .03); differences for patients aged

Objective To determine the effect of state-level dependent coverage expansion (DCE) with and without other state health reforms on exit from dependent coverage for adolescents and young adults (AYA). Data Sources Administrative longitudinal data for 131,542 privately insured AYA in Massachusetts (DCE with other reforms) versus Maine and New Hampshire (DCE without other reforms) across three periods: prereform (1/00–12/06), poststate reform (1/07–9/10), and postfederal reform (10/10–12/12). Study Design A difference-in-differences estimator was used to determine the rate of exit from dependent coverage, age at exit from dependent coverage, and re-uptake of dependent coverage among AYA in states with comprehensive reforms versus DCE only. Principal Findings Implementation of DCE with other reforms was significantly associated with a 23 percent reduction in exit from dependent coverage among AYA compared to the reduction observed for DCE alone. Additionally, comprehensive reforms were associated with over two additional years of dependent coverage for the average AYA and a 33 percent increase in the odds of regaining dependent coverage after a prior loss. Conclusions Findings suggest that an individual mandate and other reforms may enhance the effect of DCE in preventing loss of coverage among AYA.

This analysis of survey data presents national estimates of food insecurity prevalence within the Medicare population.

With emerging global payment structures, medical systems need to understand longer-term impacts of care transition strategies.To determine the effect of a care transition program using patient navigators (PNs) on health service utilization among high-risk safety-net patients over a 180-day period.Randomized controlled trial conducted October 2011 through April 2013.Patients admitted to the general medicine service with ≥1 readmission risk factor: (1) age ≥ 60; (2) in-network inpatient admission within prior 6 months; (3) index length of stay ≥ 3 days; or (4) admission diagnosis of heart failure or (5) chronic obstructive pulmonary disease. The analytic sample included 739 intervention patients, 1182 controls.Through hospital visits and 30 days of post-discharge telephone outreach, PNs provided coaching and assistance with medications, appointments, transportation, communication with primary care, and self-care.Primary outcomes: (1) hospital-based utilization, a composite of ED visits and hospital admissions; (2) hospital admissions; (3) ED visits; and (4) outpatient visits. We evaluated outcomes following an index discharge, stratified by patient age (≥ 60 and60 years), using a 180-day time frame divided into six 30-day periods.The PN program produced starkly different outcomes by patient age. Among older PN patients, hospital-based utilization was consistently lower than controls, producing an 18.7% cumulative decrease at 180 days (p = 0.038); outpatient visits increased in the critical first 30-day period (p = 0.006). Among younger PN patients, hospital-based utilization was 31.7% (p = 0.038) higher at 180 days, largely reflecting sharply higher utilization in the initial 30 days (p = 0.002), with non-significant changes thereafter; outpatient visits experienced no significant changes.A PN program serving high-risk safety-net patients differentially impacted patients based on age, and among younger patients, outcomes varied over time. Our findings highlight the importance for future research to evaluate care transition programs among different subpopulations and over longer time periods.

OBJECTIVE. There is concern that high-deductible health plans may have negative effects on vulnerable groups. The objective of this study was to compare the characteristics of families who have children and switch to high-deductible health plans with those who stay in traditional plans.METHODS. This double-cohort study included families who had children aged RESULTS. We identified 839 families who had children and whose employer switched them to high-deductible health plans and 5133 controls. Among families with large employers, the adjusted odds of the employer switching to a high-deductible health plan were higher for families living in high-poverty neighborhoods. Among families with small employers, the adjusted odds of the employer switching to a high-deductible health plan were lower for families with more children, above-average family morbidity, and baseline total expenditures >$7000.CONCLUSIONS. Among families with large employers offering a single health plan, those from low-income neighborhoods are more likely to be switched to high-deductible health plans. In contrast, families with small employers offering a single plan are more likely to be switched to high-deductible health plans if they are healthier and have lower baseline costs. These findings suggest that families with children in high-deductible plans may represent two distinct groups, one with higher-risk characteristics and another with lower-risk characteristics compared with those in traditional plans.

PURPOSE: We describe national patterns of health insurance coverage and care accessibility and affordability in a national sample of adult childhood cancer survivors (CCS) compared to adults without cancer. METHODS: Using data from the 2010–2014 National Health Interview Survey (NHIS), we selected a sample of all CCS age 21 to 65 years old and a 1:3 matched sample of controls without a history of cancer. We examined insurance coverage, care accessibility and affordability in CCS and controls. We tested for differences in the groups in bivariate analyses and multivariable logistic regression models. RESULTS: Of all respondents age 21–65 in the full NHIS sample, 443 (0.35 %) were CCS. Fewer CCS were insured (76.4 %) compared to controls (81.4 %, p=0.067). Significantly more CCS reported delaying medical care (24.7 vs 13.0 %), needing but not getting medical care in the previous 12 months (20.0 vs 10.0 %), and having trouble paying medical bills (40.3 vs 19.7 %) compared to controls (p

Although asthma treatment guidelines recommend daily inhaled corticosteroid (ICS) use for all persistent asthma, pediatricians may recommend alternative treatment plans for children with mild persistent disease. The authors administered a survey of pediatricians to describe prescribing patterns for mild persistent asthma. More than 99% of providers agreed that periodic ICS could be effective for some asthma patients. Overall, 129/251 providers (51%) reported prescribing daily ICS to most patients with mild persistent asthma, whereas 78 (31%) reported recommending periodic ICS for most such patients. Providers with patient populations ≥ 25% black were significantly less likely to report prescribing daily ICS (odds ratio, 0.3; 95% confidence interval, 0.2-0.6) for mild persistent asthma. Further research is needed on the effectiveness of periodic ICS use for children with mild persistent asthma and on underlying reasons for differing provider practice patterns.

Importance A timely, well-coordinated transfer from pediatric- to adult-focused primary care is an important component of high-quality health care, especially for youths with chronic health conditions. Current recommendations suggest that primary-care transfers for youths occur between 18 and 21 years of age. However, the current epidemiology of transfer timing is unknown. Objective To examine the timing of transfer to adult-focused primary care providers (PCPs), the time between last pediatric-focused and first adult-focused PCP visits, and the predictors of transfer timing. Design, Setting, and Participants Retrospective cohort study of patients insured by Harvard Pilgrim Health Care (HPHC), a large not-for-profit health plan. Our sample included 60 233 adolescents who were continuously enrolled in HPHC from 16 to at least 18 years of age between January 2000 and December 2012. Pediatric-focused PCPs were identified by the following provider specialty types, but no others: pediatrics, adolescent medicine, or pediatric nurse practitioner. Adult-focused PCPs were identified by having any provider type that sees adult patients. Providers with any specialty provider designation (eg, gastroenterology or gynecology) were not considered PCPs. Main Outcomes and Measures We used multivariable Cox proportional hazards regression to model age at first adult-focused PCP visit and time from the last pediatric-focused to the first adult-focused PCP visit (gap) for any type of office visit and for those that were preventive visits. Results Younger age at transfer was observed for female youths (hazard ratio [HR], 1.32 [95% CI, 1.29-1.36]) who had complex (HR, 1.06 [95% CI, 1.01-1.11]) or noncomplex (HR, 1.08 [95% CI, 1.05-1.12]) chronic conditions compared with those who had no chronic conditions. Transfer occurred at older ages for youths who lived in lower-income neighborhoods compared with those who lived in higher-income neighborhoods (HR, 0.89 [95% CI, 0.83-0.95]). The gap between last pediatric-focused to first adult-focused PCP visit was shorter for female youths than male youths (HR, 1.57 [95% CI, 1.53-1.61]) and youths with complex (HR, 1.35 [95% CI, 1.28-1.41]) or noncomplex (HR, 1.24 [95% CI, 1.20-1.28]) chronic conditions. The gap was longer for youths living in lower-income neighborhoods than for those living in higher-income neighborhoods (HR, 0.80 [95% CI, 0.75-0.85]). Multivariable models showed an adjusted median age at transfer of 21.8 years for office visits and 23.1 years for preventive visits and an adjusted median gap length of 20.5 months for office visits and 41.6 months for preventive visits. Conclusions and Relevance Most youths are transferring care later than recommended and with gaps of more than a year. While youths with chronic conditions have shorter gaps, they may need even shorter transfer intervals to ensure continuous access to care. More work is needed to determine whether youths are experiencing clinically important lapses in care or other negative health effects due to the delayed timing of transfer.

Socioeconomic disparities have been documented for children and adults in access to and use of health care, and in health outcomes (Agency for Healthcare Research and Quality 2003). Socioeconomic disparities may also exist in the financial burden of illness, particularly since low-income individuals are more likely to lack the protection of health insurance (Holl et al. 1995; Institute of Medicine Committee on the Consequences of Uninsurance 2001). Even with insurance, cost is still reported as a large barrier to receiving needed care for those with lower incomes (Davidoff 2004). Data from the 1970s and 1980s showed that poor and inadequately insured children and families experienced a greater burden of out-of-pocket (OOP) expenditures (Berki et al. 1985; Newacheck and Halfon 1986b; Wyszewianski 1986; Dicker and Sunshine 1988; Rasell, Bernstein, and Tang 1994). Since then, Medicaid expansions and the State Children's Health Insurance Program (SCHIP) have improved access and utilization for low-income women and children (Long and Marquis 1998; Banthin and Selden 2003; Szilagyi et al. 2004). While it has been documented that insurance coverage improves access and use for low-income children and adults (Newacheck 1988; St. Peter, Newacheck, and Halfon 1992; Newacheck et al. 1998; Kasper, Giovannini, and Hoffman 2000; Dubay and Kenney 2004), it is not clear whether insurance coverage has the presumed effect of reducing the financial burden of OOP health care expenditures. Medicaid expansions for children appear to have reduced the financial burden for families of Medicaid-eligible children (Banthin and Selden 2003). However, these children still had greater financial burden than higher-income children, and more than one-fifth of their families paid more than 10 percent of their family income for their child's health care expenditures. Other data from the 1996 Medical Expenditure Panel Survey (MEPS) showed that poor families appeared to be less likely to be protected from catastrophic health care expenditures compared with higher income families, regardless of the type of insurance (Waters, Anderson, and Mays 2004). It is important to consider the financial burden of health care expenditures at the level of the family, particularly since children's access, utilization, and insurance coverage are intertwined with that of their parents (Newacheck and Halfon 1986a; Hanson 1998; Guendelman and Pearl 2004). Catastrophic costs for one family member may create a financial burden felt by the whole family, and could affect the decision to seek and pay for care for other family members. The issue of family financial burden has not been examined since the enactment of SCHIP. Many states have focused recent policy initiatives toward extending SCHIP coverage to parents of eligible children in an attempt to improve access to care for both children and parents. Hence, understanding financial burden at the family level takes on added importance, especially for low-income families targeted by public programs like SCHIP. Additionally, the separate effects of income and insurance have not been assessed in a multivariate manner that also controls for potential confounders such as health status and utilization. In order to address these gaps, the objectives of this study were as follows: (1) to determine whether socioeconomic disparities exist in the financial burden of OOP health care expenditures for families with children and (2) to determine the extent to which health insurance coverage decreases the financial burden of OOP health care expenditures for low-income families with children.

Purpose To examine health care spending patterns for U.S. adolescents aged 10 to 18 years using nationally representative household survey data. Methods We analyzed data from the 1997 Medical Expenditure Panel Survey on total expenditures and out-of-pocket expenditures for health care based on a sample of 4882 adolescents. Results Compared with that for adults, health care expenditures for adolescents were low, averaging $799 per adolescent in 1997. Disabled and functionally impaired adolescents had disproportionately high expenditures ($1960 per capita). Blacks and adolescents living in poor families had disproportionately low expenditures ($358 and $609 per capita, respectively). Professional services provided by physicians and dentists accounted for more than one-half of all health care spending for adolescents. Only 2% of adolescents were hospitalized in 1997, but they accounted for about one-fifth of all health care expenditures. The share of health expenditures paid out of pocket varied by type of service, ranging from 3% for inpatient hospital care to 51% for dental care. When covered, insurance provided substantial financial protection for families of adolescents: those with public coverage paid 8%, those with private coverage paid 32%, and those without coverage paid 61% of their health care bills out of pocket. The share of health care bills paid out of pocket would be much lower if dental care was excluded. Conclusions On the basis of our findings that health care expenditures for adolescents are low and that insurance coverage provides critically needed financial protection, we conclude that further expansions of public and private health insurance coverage for this population would provide significant benefits at modest additional cost. Additional efforts to improve coverage of services that are not now well-covered, such as dental care, would also be valuable.

Background Evidence-based interventions to reduce hospital readmissions may not generalize to resource-constrained safety-net hospitals.

In the United States, steadily rising health care expenditures comprise a substantial portion of our national economy and affect the personal economy of nearly every family (Martin et al. 2012). Particularly in light of the recent recession, managing these rising costs is increasingly problematic for U.S. families, as there have not been commensurate increases in family income and families may not be protected by the provision of health insurance benefits (DeNavas-Walt, Proctor, and Smith 2012). Even the insured face mounting out-of-pocket health care costs (OOPCs) stemming from increased cost-sharing, such as higher premiums, deductibles, copayments, and reduced benefits (Gabel et al. 2003; Yu, Dick, and Szilagyi 2008; Whitmore et al. 2011). While such rising health care costs and insurance issues have the potential to be at least partially mitigated through recent federal legislation (i.e., the Affordable Care Act), the extent to which these problems will wax or wane as health reform is rolled out remains unknown. The rise in OOPC may place a heavy financial burden on U.S. families, affecting their access to needed care (Wisk and Witt 2012) and ultimately their subsequent health outcomes. Many families will experience some level of health care–related OOPC, particularly for those whose members have a chronic or complex medical condition (Newacheck, Inkelas, and Kim 2004; Kuhlthau et al. 2005; Newacheck and Kim 2005; Houtrow, Kim, and Newacheck 2008; Witt et al. 2011). Evidence from the RAND Health Insurance Experience and other studies of the effects of cost-sharing on health care use suggest that increased cost-sharing and OOPC are associated with decreased health care utilization (Newhouse et al. 1981; Keeler and Rolph 1983; Shapiro, Ware, and Sherbourne 1986; Manning et al. 1987). However, these studies are not able to identify the point at which high OOPC becomes “burdensome.” Family financial burden has been conceptually defined as the family's perception of financial stress and worry caused by inadequate monetary resources to meet the family's fiscal demands (McCubbin, Sussman, and Patterson 1983; Kahn and Pearlin 2006); while health care-related financial burden can also be exemplified by delaying or forgoing needed health care because of cost (Wisk and Witt 2012). As problems paying medical bills and medical debt have been associated with unmet health care need (May and Cunningham 2004; Doty, Edwards, and Holmgren 2005; Collins et al. 2008; Cunningham and Felland 2008; Herman, Rissi, and Walsh 2011; Robertson and Collins 2011), there is a need for an objective measure of financial burden that can predict unmet health care need due to cost. However, there is a paucity of evidence regarding how unmet need (resulting from the subjective perception of burden) and objective measures of financial burden correlate, and if the relationship between subjective perception and OOPC is moderated by other factors, such as family income. Most frequently, financial burden is objectively characterized as the percentage of income spent on OOPC, with cut-points of 5 or 10 percent applied to signify financial burden versus “normal” costs (Galbraith et al. 2005; Kuhlthau et al. 2005; Banthin and Bernard 2006; Banthin, Cunningham, and Bernard 2008; Houtrow, Kim, and Newacheck 2008). The 10 percent cut-point originally came about nearly 30 years ago in defining the term “underinsurance” (Farley 1985), but it may no longer be relevant in light of more recent evidence that points to substantially higher OOPC relative to family income for many U.S. families (Yu, Dick, and Szilagyi 2008). Furthermore, the relevance of any cut-point is likely different across levels of family income, as the percentage of income spent on OOPC is greater for lower income families (Galbraith et al. 2005).

Importance The Patient Protection and Affordable Care Act (ACA) includes subsidies that reduce patient cost sharing for low-income families. Limited information on the effects of cost sharing among children is available to guide these efforts. Objective To examine the associations between cost sharing, income, and care seeking and financial stress among children with asthma. Design, Setting, and Participants A telephone survey in 2012 about experiences during the prior year within an integrated health care delivery system. Respondents included 769 parents of children aged 4 to 11 years with asthma. Of these, 25.9% of children received public subsidies; 21.7% were commercially insured with household incomes at or below 250% of the federal poverty level (FPL) and 18.2% had higher cost-sharing levels for all services (eg, ≥$75 for emergency department visits). We classified children with asthma based on (1) current receipt of a subsidy (ie, Medicaid or Children’s Health Insurance Program) or potential eligibility for ACA low-income cost sharing or premium subsidies in 2014 (ie, income ≤250%, 251%-400%, or >400% of the FPL) and (2) cost-sharing levels for prescription drugs, office visits, and emergency department visits. We examined the frequency of changes in care seeking and financial stress due to asthma care costs across these groups using logistic regression, adjusted for patient/family characteristics. Main Outcomes and Measures Switching to cheaper asthma drugs, using less medication than prescribed, delaying/avoiding any office or emergency department visits, and financial stress (eg, cutting back on necessities) because of the costs of asthma care. Results After adjustment, parents at or below 250% of the FPL with lower vs higher cost-sharing levels were less likely to delay or avoid taking their children to a physician’s office visit (3.8% vs 31.6%; odds ratio, 0.07 [95% CI, 0.01-0.39]) and the emergency department (1.2% vs 19.4%; 0.05 [0.01-0.25]) because of cost; higher-income parents and those whose children were receiving public subsidies (eg, Medicaid) were also less likely to forego their children’s care than parents at or below 250% of the FPL with higher cost-sharing levels. Overall, 15.6% of parents borrowed money or cut back on necessities to pay for their children’s asthma care. Conclusions and Relevance Cost-related barriers to care among children with asthma were concentrated among low-income families with higher cost-sharing levels. The ACA’s low-income subsidies could reduce these barriers for many families, but millions of dependents for whom employer-sponsored family coverage is unaffordable could remain at risk for cost-related problems because of ACA subsidy eligibility rules.

To pilot-test the feasibility and preliminary effect of a community health worker (CHW) intervention to reduce hospital readmissions.Patient-level randomized quality improvement intervention.An academic medical center serving a predominantly low-income population in the Boston, Massachusetts area and 10 affiliated primary care practices.Medical service patients with an in-network primary care physician who were discharged to home (n = 423) and had one of five risk factors for readmission within 30 days.Inpatient introductory visit and weekly post-discharge telephonic support for 4 weeks to assist patient in coordinating medical visits, obtaining and using medications, and in self-management.Number of completed CHW contacts; CHW-reported barriers and facilitators to assisting patients; primary care, emergency department and inpatient care use.Roughly 70% of patients received at least one post-discharge CHW call; only 38% of patients received at least four calls as intended. Hospital readmission rates were lower among CHW patients (15.4%) compared with usual care (17.9%); the difference was not statistically significant.Under performance-based payment systems, identifying cost-effective solutions for reducing hospital readmissions will be crucial to the economic survival of all hospitals, especially safety-net systems. This pilot study suggests that with appropriate supportive infrastructure, hospital-based CHWs may represent a feasible strategy for improving transitional care among vulnerable populations. An ongoing, randomized, controlled trial of a CHW intervention, developed according to the lessons of this pilot, will provide further insight into the utility of this approach to reducing readmissions.

Background/Aims Poor care coordination at hospital discharge can result in avoidable hospital readmissions. This study’s aim was to evaluate the effect of a community health worker (CHW) intervention, the Patient Navigator (PN), on readmission rates and post-discharge health care use in a safety net population.