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Financial Barriers to Care Among Low-Income Children With Asthma:  Health Care Reform Implications

Vicki Fung, PhD1,2; Ilana Graetz, PhD3,4; Alison Galbraith, MD, MPH5; Courtnee Hamity, MPH3,6; Jie Huang, PhD3; William M. Vollmer, PhD7; John Hsu, MD, MBA, MSCE1,2,8; Ann Chen Wu, MD, MPH5
[+] Author Affiliations
1Mongan Institute for Health Policy, Massachusetts General Hospital, Boston
2Department of Medicine, Harvard Medical School, Boston, Massachusetts
3Division of Research, Kaiser Permanente Northern California, Oakland
4Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis
5Center for Child Health Care Studies, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
6School of Public Health, University of California, Berkeley
7Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
8Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
JAMA Pediatr. 2014;168(7):649-656. doi:10.1001/jamapediatrics.2014.79.
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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.

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Frequency of Cost Responses

The unadjusted frequency of cost responses in the overall population weighted for sampling proportions. Limit lines indicate 95% confidence intervals. ED indicates emergency department.

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