PURPOSE OF THE STUDY.
Increased cost sharing, or making people pay more out-of-pocket for their health care, is associated with decreased spending but without worse health outcomes. However, previous studies consisted of mostly healthy people without chronic disease. The objective of this study was to examine the associations between cost sharing/income and care seeking/financial stress among children with asthma under the Patient Protection and Affordable Care Act (ACA).
Telephone surveys were performed within the Kaiser Permanente Northern California health care delivery system. Respondents were 769 parents of children aged 4 to 11 years with asthma (59% response rate). Children receiving omalizumab or long-term oral corticosteroids were excluded.
Survey items addressed various costs of asthma care, including switching to cheaper drugs, using less medication than prescribed, delaying/avoiding office or emergency department visits, and financial stress because of costs of asthma care. In California, the income limits in 2011 for children 6 to 18 years were 100% of the federal poverty level (FPL) for Medicaid and 250% of the FPL for CHIP (Children’s Health Insurance Program). Families were stratified by (1) current receipt of a subsidy or potential eligibility for ACA subsidy in 2014 and (2) cost-sharing levels for prescription drugs, office visits, and emergency department visits.
Parents at or below the 250% of the FPL with lower out-of-pocket costs were less likely to delay/avoid office visit (3.8% vs 31.6%; odds ratio 0.07, 95% confidence interval: 0.01–0.39) and the emergency department (1.2% vs 19.4%; 0.05, 0.01–0.25) compared with those with higher cost-sharing levels. Moreover, 33.3% of this group borrowed money to pay for their children’s asthma care. Commercially insured children in families who earned <250% of the FPL were more likely to avoid or delay care and more likely to borrow money than those who had higher incomes as well as those with Medicaid.
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 but only for families who qualify under subsidy eligibility rules.
Families making <250% of the federal poverty level who obtain insurance in the exchanges are more likely to avoid or delay care than face financial stress in caring for their children with asthma. These results may be conservative because indirect costs were not assessed and commercially insured children in this study had more generous benefits than the national average among employer plans. Moreover, children with severe asthma, who likely have even greater health care needs and costs, were excluded in this study. Although the ACA reduced the numbers of uninsured, obtaining appropriate health care is still difficult for many.
- Copyright © 2015 by the American Academy of Pediatrics