The Centers for Disease Control estimates that nine people die from asthma every day in the United States. Children are particularly affected by the condition; child asthma prevalence rates as high as 20–40 percent have been reported in some poor and minority communities. Asthma costs the United States a staggering $56 billion each year in direct health care costs, including preventable hospitalizations and emergency department (ED) visits, and in indirect costs related to premature death and missed school and work days.
Yet despite asthma's huge quality of life and economic impact, for years, many patients and caregivers have been frustrated by not having the tools to control the disease. We know that language- and literacy-appropriate education on how to control symptoms, assistance with assessing and modifying asthma “triggers” at home, and access to affordable medications can all help patients control their asthma. But even with that knowledge it has been persistently difficult to tackle the disease.
Enter the Affordable Care Act (ACA). While the ACA may not contain extensive language specifically targeting asthma, or for that matter any other chronic disease, many stakeholders are betting on the ACA's potential to improve quality of life for people with asthma and to reduce asthma disparities. As envisioned, ACA reforms can potentially address, at the individual level, many important personal and systemic barriers that get in the way of persons with asthma getting the care they need. At the population level, the law has the potential to improve outcomes and improve efficiency and equity of services for chronic conditions such as asthma for which cost-effective preventive treatments exist. Some examples of how the ACA may help include:
Provide access to health insurance to a greater number of people with asthma. Many persons with chronic illness don't have health insurance because they can't afford it; they are not eligible (i.e., asthma can be considered a pre-existing condition); they earn too much to be eligible for Medicaid; their employer does not offer it; and/or they don't know they need it or how to get it. Various provisions of the ACA are designed to address these challenges and increase rates of insurance.
Provide better benefit packages for preventive services for asthma. This could include, for example, necessary medications and medical equipment at no cost or with affordable co-pays, reimbursement for asthma education and care coordination in community settings, and regular “asthma checkups.” Beyond ACA reforms, a new rule states that Medicaid can begin paying for preventive services delivered in community settings, such as asthma education in the home, when it is prescribed by a clinician.
Increase financial incentives for preventive primary asthma care. A lot of pre-ACA asthma care has been provided through a safety net system that undervalues prevention and coordination services because they are poorly reimbursed compared to ED and hospital care. The ACA shifts payment policies to actually give health care provider organizations an incentive to provide outpatient preventive care to reduce hospitalization and ED costs.
Improve coordination of asthma services in community settings. Quality improvement and care coordination interventions — integrating clinical assessment and therapy, patient and family education, home trigger assessment and reduction, and linguistically- and culturally-concordant community health care workers (navigators) — have already made significant inroads in decreasing asthma disparities and costs in several communities nationwide. Because the ACA prioritizes improved coordination of care, as well as prevention, its implementation could significantly scale up these interventions through improved coverage for community asthma services, and promotion of a culture that values quality community-based primary care for all persons with asthma, including populations who experience greater barriers to care in spite of disproportionate suffering from the condition.
But just as there are promising aspects of the ACA, there are some potential areas of concern as its implementation is taking shape. Will low income and minority patients be able to access and navigate the online marketplaces? Will they be able to afford the insurance plans available through the exchanges? And how will differences in Medicaid implementation across states, including coverage of community services, affect persons with asthma, both in states that have opted into the expansion and, particularly, in those that haven't?
Given these and other uncertainties, only time will tell if the ACA will be able to fix some significant problems with the U.S. asthma health care system. But many will be anxiously watching to find out if at last they might be able to breathe a bit easier.
Marielena Lara, M.D., M.P.H., is a senior natural scientist at the nonprofit, nonpartisan RAND Corporation.
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