Results Summary
What was the research about?
Asthma is a health problem that makes it hard for people to breathe. People often rely on insurance plans to help pay for care and medicine to control asthma. But some types of plans provide more help than others. With high-deductible health plans, or HDHPs, people pay more toward the cost of their care than they do with low-deductible plans. Higher costs may affect whether people can afford medicines. For this reason, some HDHPs have a list of medicines that are free to people, like asthma medicines.
The research team wanted to learn about the impact of insurance changes on health care for people with asthma. They did two studies. The first compared people whose employer switched to an HDHP versus people who stayed on a low-deductible plan. The second compared people whose HDHP added a free medicine list versus people whose plan didn’t.
What were the results?
Compared with people who stayed on low-deductible plans, people whose employers switched to HDHPs:
- Filled fewer prescriptions for long-acting inhaled asthma control medicines and took these medicines less often
- Had higher out-of-pocket costs for asthma care
Among people on HDHPs, people whose plan added a free medicine list had lower out-of-pocket costs than people whose plan didn’t add such a list. Use of asthma control medicines didn’t differ between the two groups.
The two studies found no differences in:
- Use of other types of asthma control medicines, like pills or short-acting inhaled asthma control medicines
- Asthma attacks
- How often people filled prescriptions for albuterol, a medicine used during an asthma attack, or spacers, which hold asthma inhalers in place, making it easier to breathe the medicine in
What did the research team do?
The research team reviewed insurance claims for people with asthma. All had insurance through their jobs.
Study 1 included insurance claims from 2002 to 2014 for 184,579 children and adults ages 4–64 who had asthma. Of these, 72 percent were White, 7 percent were Hispanic, 2 percent were Asian, 2 percent were Black, and 18 percent were more than one race or ethnicity. Also, 54 percent were women.
Study 2 included claims from 2004 to 2017 for 12,174 children and adults ages 4–64 who had asthma. Of these, 78 percent were White, 7 percent were Black, and 7 percent were Hispanic; 56 percent were women.
People with asthma, parents of children with asthma, a drug company, insurers, employers, and patient groups gave input on the study.
What were the limits of the study?
The study didn’t account for some differences between people whose plans did and didn’t change, like how severe their asthma was. These differences may have affected the results.
Future research could look at how HDHPs affect people with severe asthma and at other health outcomes like family stress and well-being.
How can people use the results?
People with asthma and employers can use the results when considering types of insurance.
Professional Abstract
Objective
To compare the effects of high-deductible health plans (HDHPs) versus traditional insurance plans, and of adding a preventive drug list to an HDHP, on medication use, asthma exacerbations, and out-of-pocket costs among people with asthma
Study Design
| Design Element | Description |
|---|---|
| Design | Observational: cohort studies |
| Population | Two studies using insurance claims data from a large national health plan: Study 1: 52,824 children ages 4–17 and 131,755 adults ages 18–64 with asthma and employer-sponsored insurance coverage Study 2: 1,923 children ages 4–17 and 10,251 adults ages 18–64 with asthma and employer-sponsored insurance coverage |
| Interventions/ Comparators |
Study 1:
Study 2:
|
| Outcomes |
Primary: asthma controller medication fill rates for inhaled corticosteroids, leukotriene inhibitors, combination inhaled corticosteroids, and long-acting beta agonists; asthma controller medication adherence; asthma exacerbations; out-of-pocket costs Secondary: albuterol inhaler fill rates, inhaler spacer dispensing rates |
| Timeframe | 1-year follow-up for primary outcomes |
These retrospective cohort studies examined the impact of employer-mandated changes in insurance coverage on patient-centered asthma outcomes among adults and children with asthma. Researchers used insurance claims from two cohorts of people who were propensity-matched for employee and employer characteristics.
Study 1. Researchers compared people with asthma who had a traditional health plan for at least one year and then had an employer-mandated change to an HDHP versus people who stayed on a traditional plan. An HDHP requires people to pay more toward the cost of their health care than a traditional plan.
The study included claims data from 2002 to 2014 for 184,579 children and adults with asthma who had insurance coverage through a large national health plan. Among these people, 72% were White, 7% were Hispanic, 2% were Black, 2% were Asian, and 18% were more than one race or ethnicity. Also, 54% were female.
Study 2. Researchers compared outcomes among people with asthma who had an HDHP for at least one year and whose employers added a preventive drug list that included asthma medications, versus people whose employer did not add a preventive drug list. Medications on preventive drug lists are covered with low or no copays and are exempted from the high deductible.
The study included data from 2004 to 2017 for 12,174 children and adults with asthma. Among these people, 78% were White, 7% were Black, and 7% were Hispanic; 56% were female.
People with asthma, parents of children with asthma, health insurers, employers, a pharmaceutical company, and advocacy organizations provided input on the study.
Results
Study 1. Compared with people on traditional plans, those who changed to HDHPs had:
- Decreased fill rates for inhaled corticosteroid long-acting beta agonists (-0.04; 95% confidence interval [CI]: -0.06, -0.02) and decreased adherence (-1.6%; 95% CI: -2.6%, -0.6%)
- Increased out-of-pocket costs for asthma care ($11.54; 95% CI: $9.46, $13.63)
Other outcomes did not differ significantly between people in traditional and HDHP plans.
Study 2. Compared with people whose asthma medications were not on a preventive drug list, those whose HDHP added such a list had decreased out-of-pocket costs for asthma care (-$34; 95% CI: -$47, -$21).
Other outcomes did not differ significantly between people whose HDHPs did and did not have preventive drug lists.
Limitations
Unmeasured differences between people whose plans did and did not change may have affected the results.
Conclusions and Relevance
These cohort studies found that HDHP enrollment reduced asthma controller medication use and increased out-of-pocket costs for patients with asthma. Adding asthma medications to preventive drug lists was associated with decreased out-of-pocket costs.
Future Research Needs
Future research could explore the impact of HDHPs on people with more severe asthma and on other health outcomes, such as family stress and well-being.
COVID-19-Related Study
Testing a Health Insurance Navigation Program to Help People with Asthma Who Lost Job-Based Insurance During the Pandemic
Results Summary
In response to the COVID-19 public health crisis in 2020, PCORI launched an initiative to enhance existing research projects so that they could offer findings related to COVID-19. The initiative funded this study and others.
What was this COVID-19 study about?
During the COVID-19 pandemic, many people lost their jobs and job-based health insurance. Losing insurance can make it hard for people with asthma to afford medicines that help control asthma.
In this study, the research team tested a navigation program to help people with asthma who lost their insurance to get it back. In the program, an asthma navigator contacted people and provided additional help as needed. People also had access to an online community and a chat bot, or interactive online tool, to ask questions. The team compared people with and without access to the program. They also interviewed people about how losing health insurance affected them.
What were the results?
Few people used the program. Of the 14 people with access who completed surveys, 4 read online posts, 2 reported getting additional messages from the navigator, and none used the chat bot. After four months, people with and without access to the program didn’t differ in:
- Having health insurance
- Asthma medicine use
- Delayed or missed asthma care visits
- Burden related to healthcare costs
During interviews, people said they didn’t use the program because they had gotten new insurance and no longer needed it, or other issues overwhelmed them.
People also said:
- Loss of insurance worsened their asthma care.
- It was hard to pay for both asthma care and other needs, like food and rent.
- Resources like stimulus checks and family or friends helped with the costs of care.
- New insurance options were unfamiliar and expensive compared to what they had lost.
Who was in the study?
The study included 37 people who either had asthma or were parents of children with asthma. All had lost job-based health insurance during the pandemic. Of these, 83 percent were White, 7 percent were Black, 7 percent were more than one race, and 2 percent were Pacific Islander; 13 percent were Hispanic. Also, 82 percent were women.
What did the research team do?
The research team recruited people who had lost insurance coverage from a large, private insurer and from an online asthma community. The team assigned one-third of people by chance to the program and two-thirds to a comparison group. The people in the comparison group got access to the program at the end of the study.
People completed online surveys when they started the study and one and four months later.
The research team also interviewed 21 people in the trial about insurance and asthma care during the pandemic.
People with asthma, parents of children with asthma, drug companies, insurers, employer groups, and asthma advocacy groups gave input on the study.
What were the limits of the study?
Fewer people took part in the study than planned; results may have differed if more people took part.
How can people use the results?
Policy makers and patient organizations can use these results when considering ways to help people with asthma who lose job-based health insurance.
Professional Abstract
In response to the COVID-19 public health crisis in 2020, PCORI launched an initiative to enhance existing research projects so that they could offer findings related to COVID-19. The initiative funded this study and others.
Background
During the COVID-19 pandemic, many people lost their insurance coverage due to unemployment. For people with asthma, loss of coverage could make it difficult to afford asthma medications or lead to delayed or missed care.
Objective
(1) To pilot test a navigation intervention to regain insurance coverage among people with asthma who lost employer-sponsored coverage during the pandemic; (2) To understand the experiences of people with asthma who lost employer-sponsored coverage during the pandemic
Study Design
| Design Element | Description |
|---|---|
| Design | Randomized controlled trial; interviews |
| Population | Randomized controlled trial: 37 adults including adults with asthma and parents of children with asthma who lost employer-sponsored health insurance coverage during the COVID-19 pandemic Interviews: A subset of 21 people that included people with asthma and parents of children with asthma who lost employer-sponsored health insurance coverage during the COVID-19 pandemic |
| Outcomes | Having health insurance coverage, asthma medication use, delayed or missed asthma care, healthcare-related financial burden, asthma control, health status, non-medical cost problems |
| Data Collection Timeframe | December 2020–August 2021 |
This randomized controlled trial examined the effects of a navigation intervention on regaining insurance coverage, medication use, delayed or missed care, and financial burden among people with asthma who lost insurance coverage during the pandemic.
Researchers recruited people who had lost coverage from a large private health plan and people from an online asthma community. The trial included 37 adults with asthma and parents of children with asthma. Researchers randomly assigned one-third of participants to receive the navigation intervention and remaining participants to a waitlisted comparison group. The intervention included a trained asthma navigator who contacted people and assisted as needed. People also had access to an online asthma community platform with an artificial-intelligence-enabled interactive online tool, or chat bot, which provided insurance navigation. In the comparison group, participants received access to the intervention after four months, at the end of the study.
Participants completed online surveys at baseline and one and four months later. Among participants, 83% were White, 7% were Black, 7% were more than one race, and 2% were Pacific Islander; 13% were Hispanic. Also, 82% were female.
Researchers also interviewed 21 people in the trial about their experiences obtaining insurance coverage and asthma care during the pandemic.
Adults with asthma, parents of children with asthma, and representatives from a pharmaceutical company, insurers, employer groups, and asthma advocacy organizations gave input on the study.
Results
Navigation use was minimal. Of the 14 people who received the intervention and completed surveys at four months, only four reported reading online posts and two recalled private messages from the navigator; none used the chat bot. At four months, people with and without access to the intervention did not differ significantly in insurance status, use of asthma medications, delayed or foregone asthma care visits, or financial burden.
During interviews, people reported not using navigation because they felt overwhelmed with other issues or had already obtained coverage. People also reported that:
- Loss of coverage negatively affected asthma care.
- Paying for both asthma care and non-medical needs, like food and rent, was challenging.
- Using resources like stimulus checks and social support networks helped mitigate costs.
- Insurance options for regaining coverage were unfamiliar and more costly than the coverage they lost.
Limitations
The study did not reach its recruitment goal, which limited the ability to detect differences between the groups.
Conclusions and Relevance
In this pilot study, an insurance navigation intervention did not improve outcomes. People reported that loss of employer-sponsored insurance coverage led to compromised asthma care, unmet asthma needs, and increased financial burden.
Peer Review Summary
The Peer-Review Summary for this COVID-19 study will be posted here soon.
Final Enhancement Report
This COVID-19 study's final enhancement report is expected to be available by December 2023.
Final Research Report
This project's final research report is expected to be available by December 2023.
Journal Citations
Related Journal Citations
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:
- The reviewers questioned the researchers’ approach to missing data, particularly as related to imputation of missing deductible levels. The researchers added information to their appendix about their imputation model, methods for estimating accuracy, and their percent of enrollees with imputed deductible data.
- The reviewers noted that the report was unclear on what variables were included in the data matching models for aim 3 of the report. The researchers added information to the report’s section on matching, indicating that the covariates for the models were noted in the footnote of one of the results tables.
- The reviewers asked the researchers to provide justification for excluding data from the last month of the baseline year and the first month of the follow-up year. The researchers explained that they had found that for enrollees in the high-deductible health plans (HDHPs), participants would stockpile medications at the end of the year, which also led to a decline in medication use at the beginning of the next year. These changes could affect the analyses, so the two months were left out.
- The reviewers noted the low proportion of Black or Hispanic/Latino/a study participants and wondered whether this could be related to the types of people who enroll in HDHPs. The researchers acknowledged that their study sample had lower proportions of these patients with asthma than the general population, which they agreed could be a reflection of population characteristics for commercially insured individuals.
- The reviewers asked the researchers to elaborate on the implications of the small sample size and low participation in their COVID-19 enhancement project. The researchers expanded their discussion regarding the limited conclusions that are possible for this enhancement project but indicated that there was much to learn from this project regarding the feasibility and acceptability of navigation interventions. They also discussed alternative strategies for future research.