Health care affordability, racial disparities persist in individuals with asthma, COPD

Health insurance coverage losses among patients with asthma and COPD improved after implementation of the Affordable Care Act, but there was no improvement in health care affordability or racial and economic disparities from 1997 to 2018.

“Financial barriers to care are associated with worse outcomes, including more disease exacerbations, among persons with asthma and COPD and could contribute to entrenched disparities in respiratory health,” Adam W. Gaffney, MD, MPH, assistant professor of medicine at the Cambridge Health Alliance at Harvard Medical School, and colleagues wrote in Chest. “Understanding long-term trends in barriers that obstruct care could help pulmonary physicians address their patients’ needs during a time of economic recession and help inform the debate about reforms to improve coverage and access for those with chronic respiratory disease.”

Researchers examined time trends in health care coverage, medical care affordability and prescription drugs among 76,843 adults with asthma and 30,548 adults with COPD overall and by income and race/ethnicity. Using data from the National Health Interview Survey, the researchers compared coverage and access in 1997 vs. 2018.

The overall rate of uninsurance improved over time, from 19.4% in 1997 to 9.6% in 2018 among patients with asthma (P < .001) and from 15.1% in 1997 to 7.8% in 2018 among patients with COPD (P < .001), according to the results. The researchers noted that the uninsurance rate declined in the late 90s, rose in 2009 in the wake of the Great Recession and then fell after implementation of the ACA in 2014.

The researchers reported no significant improvements over time in the proportion of adults delaying or foregoing medical care or medications due to cost. However, they noted that “the share of COPD patients going without needed prescription drugs increased sharply over the 22-year period.

Racial/ethnic and economic disparities persisted from 1997 to 2018.

Rates of coverage in all income groups improved after the ACA, with low-income adults with asthma demonstrating the largest improvement of 10.8 percentage points. In 2018, 35.4% of low-income and 28.6% of middle-income adults with asthma had inadequate insurance coverage compared with 13.7% of high-income adults with asthma. The researchers reported similar findings in adults with COPD. From 1997 to 2018, middle-income adults with COPD experienced worsening inadequate insurance coverage with a 10.4 percentage point increase similar to high-income adults (P = .02). In 2018, 39.2% of low-income adults had inadequate coverage, 28% of middle-income adults and 17.6% of high-income adults.

There were significant improvements after the ACA among all racial/ethnic groups, but largest improvements were observed among Black and Hispanic adults with asthma. In 2018, 25.1% of Black adults, 22.6% of white adults, 29.8% of Hispanic adults and 26% of other race adults with asthma had inadequate insurance coverage. Researchers observed similar results with adults with COPD. There were 27.2% of white adults, 28% of Black adults, 38.1% of Hispanic adults and 29.5% of other race adults with COPD in 2018 who were inadequately insured.

“Our findings also raise concerns about the effects of the ongoing recession, and the COVID-19 pandemic and its aftermath, for patients with airway disease. We observed a deterioration in adequate coverage for some subgroups during the Great Recession, which paralleled trends in uninsurance experienced by the overall population at that time. The current economic downturn could have similar consequences on coverage,” the researchers wrote.