"No room for error": a qualitative interview study of experiences with health insurance coverage loss and COVID-19 pandemic relief policies among people with asthma.

OBJECTIVES: The COVID-19 pandemic led to unemployment and associated health insurance loss, prompting an unprecedented adoption of emergency policies, including economic relief efforts and health insurance coverage expansion. We sought to understand pandemic-related challenges for people with asthma and how emergency policies served families facing both chronic disease management and health insurance loss. STUDY DESIGN: Qualitative interview study. METHODS: In 2021, we conducted semi-structured telephone interviews with 21 adults who had asthma and lost employment and employer-sponsored health insurance coverage during the COVID-19 pandemic. We used thematic analysis to assess how health and economic policies affected participants' ability to access care and manage their asthma. RESULTS: Participants reported reduced access to care, as well as worry about heightened susceptibility to COVID-19 due to their asthma. While insurance loss exacerbated these challenges, participants indicated that economic relief efforts, including direct stimulus payments, helped them afford needed asthma care. Participants were more critical of enhancements to existing coverage policies such as the Affordable Care Act (ACA) Marketplace and Consolidated Omnibus Budget Reconciliation Act (COBRA) due to difficulty understanding, accessing, and affording such coverage. CONCLUSIONS: Our findings underscore that people affected by asthma and health insurance loss benefit from policies that provide flexible and easy-to-use assistance, such as direct payments, for meeting the diverse challenges posed by living with a chronic disease. Although policies that expand health insurance coverage are critical, more attention is needed to help people with chronic conditions access these programs in a timely way.

"You Have to Rob Peter to Pay Paul So Your Kid Can Breathe": Using Qualitative Methods to Characterize Trade-Offs and Economic Impact of Asthma Care Costs.

BACKGROUND: Economic analyses often focus narrowly on individual patients' health care use, while overlooking the growing economic burden of out-of-pocket costs for health care on other family medical and household needs. OBJECTIVE: The aim of this study was to explore intrafamilial trade-offs families make when paying for asthma care. RESEARCH DESIGN: In 2018, we conducted telephone interviews with 59 commercially insured adults who had asthma and/or had a child with asthma. We analyzed data qualitatively via thematic content analysis. PARTICIPANTS: Our purposive sample included participants with high-deductible and no/low-deductible health plans. We recruited participants through a national asthma advocacy organization and a large nonprofit regional health plan. MEASURES: Our semistructured interview guide explored domains related to asthma adherence and cost burden, cost management strategies, and trade-offs. RESULTS: Participants reported that they tried to prioritize paying for asthma care, even at the expense of their family's overall financial well-being. When facing conflicting demands, participants described making trade-offs between asthma care and other health and nonmedical needs based on several criteria: (1) short-term needs versus longer term financial health; (2) needs of children over adults; (3) acuity of the condition; (4) effectiveness of treatment; and (5) availability of lower cost alternatives. CONCLUSIONS: Our findings suggest that cost-sharing for asthma care often has negative financial consequences for families that traditional, individually focused economic analyses are unlikely to capture. This work highlights the need for patient-centered research to evaluate the impact of health care costs at the family level, holistically measuring short-term and long-term family financial outcomes that extend beyond health care use alone.

Strategies commercially-insured families use to manage the cost of asthma care: a qualitative interview study.

OBJECTIVE: Families affected by asthma report difficulty adhering to care regimens because of high medication costs, coupled with increased cost sharing required by some insurance plans. To inform efforts to support adherence, we conducted a qualitative study to explore how families manage asthma care costs. METHODS: We conducted phone interviews with commercially-insured, US adults (n = 59) who had asthma and/or a child with asthma. Our purposive sample included participants with high- and low/no-deductible health plans. We analyzed data using thematic content analysis to identify strategies for managing asthma care costs and to assess strategies' implications for adherence. RESULTS: Our analysis identified four overarching strategies for managing asthma care costs. First, participants used prevention strategies to avoid costly acute care by minimizing exposure to asthma triggers and adhering strictly to preventive medication regimens. Second, participants used shopping strategies to reduce costs, including by comparing medication prices across pharmacies, using medication coupons or free samples, and switching to lower-cost medications. Third, budgeting strategies involved putting aside funds, including in tax-exempt health savings accounts, or taking on debt to pay for care. Finally, some participants sought to reduce costs by forgoing recommended care, including by skipping medication doses or replacing prescribed medications with alternative therapies. CONCLUSION: Commercially-insured families use a wide range of strategies to manage asthma care costs, with both positive and negative implications for adherence. Our typology of asthma cost management strategies can inform insurance redesign and other interventions to help families safely reduce costs and maximize adherence to recommended care.

Cost-related Medication Nonadherence and Its Risk Factors Among Medicare Beneficiaries.

BACKGROUND: Unaffordability of medications is a barrier to effective treatment. Cost-related nonadherence (CRN) is a crucial, widely used measure of medications access. OBJECTIVES: Our study examines the current national prevalence of and risk factors for CRN (eg, not filling, skipping or reducing doses) and companion measures in the US Medicare population. RESEARCH DESIGN: Survey-weighted analyses included logistic regression and trends 2006-2016. SUBJECTS: Main analyses used the 2016 Medicare Current Beneficiary Survey. Our study sample of 12,625 represented 56 million community-dwelling beneficiaries. MEASURES: Additional outcome measures were spending less on other necessities in order to pay for medicines and use of drug cost reduction strategies such as requesting generics. RESULTS: In 2016, 34.5% of enrollees under 65 years with disability and 14.4% of those 65 years and older did not take their medications as prescribed due to high costs; 19.4% and 4.7%, respectively, experienced going without other essentials to pay for medicines. Near-poor older beneficiaries with incomes $15-25K had 50% higher odds of CRN (vs. >$50K), but beneficiaries with incomes <$15K, more likely to be eligible for the Part D Low-Income Subsidy, did not have significantly higher risk. Three indicators of worse health (general health status, functional limits, and count of conditions) were all independently associated with higher risk of CRN. CONCLUSIONS: Changes in the risk profile for CRN since Part D reflect the effectiveness of targeted policies. The persistent prevalence of CRN and associated risks for sicker people in Medicare demonstrate the consequences of high cost-sharing for prescription fills.

Impact of a Patient Navigator Program on Hospital-Based and Outpatient Utilization Over 180 Days in a Safety-Net Health System.

BACKGROUND: With emerging global payment structures, medical systems need to understand longer-term impacts of care transition strategies. OBJECTIVE: To determine the effect of a care transition program using patient navigators (PNs) on health service utilization among high-risk safety-net patients over a 180-day period. DESIGN: Randomized controlled trial conducted October 2011 through April 2013. PARTICIPANTS: Patients admitted to the general medicine service with ≥1 readmission risk factor: (1) age ≥ 60; (2) in-network inpatient admission within prior 6 months; (3) index length of stay ≥ 3 days; or (4) admission diagnosis of heart failure or (5) chronic obstructive pulmonary disease. The analytic sample included 739 intervention patients, 1182 controls. INTERVENTIONS: Through hospital visits and 30 days of post-discharge telephone outreach, PNs provided coaching and assistance with medications, appointments, transportation, communication with primary care, and self-care. MAIN MEASURES: Primary outcomes: (1) hospital-based utilization, a composite of ED visits and hospital admissions; (2) hospital admissions; (3) ED visits; and (4) outpatient visits. We evaluated outcomes following an index discharge, stratified by patient age (≥ 60 and < 60 years), using a 180-day time frame divided into six 30-day periods. KEY RESULTS: The PN program produced starkly different outcomes by patient age. Among older PN patients, hospital-based utilization was consistently lower than controls, producing an 18.7% cumulative decrease at 180 days (p = 0.038); outpatient visits increased in the critical first 30-day period (p = 0.006). Among younger PN patients, hospital-based utilization was 31.7% (p = 0.038) higher at 180 days, largely reflecting sharply higher utilization in the initial 30 days (p = 0.002), with non-significant changes thereafter; outpatient visits experienced no significant changes. CONCLUSIONS: A PN program serving high-risk safety-net patients differentially impacted patients based on age, and among younger patients, outcomes varied over time. Our findings highlight the importance for future research to evaluate care transition programs among different subpopulations and over longer time periods.

A Patient Navigator Intervention to Reduce Hospital Readmissions among High-Risk Safety-Net Patients: A Randomized Controlled Trial.

BACKGROUND: Evidence-based interventions to reduce hospital readmissions may not generalize to resource-constrained safety-net hospitals. OBJECTIVE: To determine if an intervention by patient navigators (PNs), hospital-based Community Health Workers, reduces readmissions among high risk, low socioeconomic status patients. DESIGN: Randomized controlled trial. PARTICIPANTS: General medicine inpatients having at least one of the following readmission risk factors: (1) age ≥60 years, (2) any in-network inpatient admission within the past 6 months, (3) length of stay ≥3 days, (4) admission diagnosis of heart failure, or (5) chronic obstructive pulmonary disease. The analytic sample included 585 intervention patients and 925 controls. INTERVENTIONS: PNs provided coaching and assistance in navigating the transition from hospital to home through hospital visits and weekly telephone outreach, supporting patients for 30 days post-discharge with discharge preparation, medication management, scheduling of follow-up appointments, communication with primary care, and symptom management. MAIN MEASURES: The primary outcome was in-network 30-day hospital readmissions. Secondary outcomes included rates of outpatient follow-up. We evaluated outcomes for the entire cohort and stratified by patient age >60 years (425 intervention/584 controls) and ≤60 years (160 intervention/341 controls). KEY RESULTS: Overall, 30-day readmission rates did not differ between intervention and control patients. However, the two age groups demonstrated marked differences. Intervention patients >60 years showed a statistically significant adjusted absolute 4.1% decrease [95% CI: -8.0%, -0.2%] in readmission with an increase in 30-day outpatient follow-up. Intervention patients ≤60 years showed a statistically significant adjusted absolute 11.8% increase [95% CI: 4.4%, 19.0%] in readmission with no change in 30-day outpatient follow-up. CONCLUSIONS: A patient navigator intervention among high risk, safety-net patients decreased readmission among older patients while increasing readmissions among younger patients. Care transition strategies should be evaluated among diverse populations, and younger high risk patients may require novel strategies.

Feasibility and evaluation of a pilot community health worker intervention to reduce hospital readmissions.

OBJECTIVE: To pilot-test the feasibility and preliminary effect of a community health worker (CHW) intervention to reduce hospital readmissions. DESIGN: Patient-level randomized quality improvement intervention. SETTING: An academic medical center serving a predominantly low-income population in the Boston, Massachusetts area and 10 affiliated primary care practices. PARTICIPANTS: Medical service patients with an in-network primary care physician who were discharged to home (n = 423) and had one of five risk factors for readmission within 30 days. INTERVENTION: Inpatient introductory visit and weekly post-discharge telephonic support for 4 weeks to assist patient in coordinating medical visits, obtaining and using medications, and in self-management. MAIN OUTCOME MEASURES: Number of completed CHW contacts; CHW-reported barriers and facilitators to assisting patients; primary care, emergency department and inpatient care use. RESULTS: Roughly 70% of patients received at least one post-discharge CHW call; only 38% of patients received at least four calls as intended. Hospital readmission rates were lower among CHW patients (15.4%) compared with usual care (17.9%); the difference was not statistically significant. CONCLUSION: Under performance-based payment systems, identifying cost-effective solutions for reducing hospital readmissions will be crucial to the economic survival of all hospitals, especially safety-net systems. This pilot study suggests that with appropriate supportive infrastructure, hospital-based CHWs may represent a feasible strategy for improving transitional care among vulnerable populations. An ongoing, randomized, controlled trial of a CHW intervention, developed according to the lessons of this pilot, will provide further insight into the utility of this approach to reducing readmissions.

Factors Associated With Repeat Pediatric Influenza Vaccination Among Inconsistent Vaccinators.

Promoting consistent vaccination practices may help improve suboptimal influenza vaccination rates. This study evaluated the prevalence and correlates of repeat influenza (flu) vaccination among children who had previously received the vaccine inconsistently. An online survey study was conducted in 2022 among parents of commercially insured children ages 3 to 19 years who were previously inconsistently vaccinated. Of 317 respondents, 85% reported that their child received a flu vaccine in the 2021 to 2022 flu season. Among these parents, 61% reported concern that their child would get sick from flu as the most important reason for vaccinating. Repeat vaccination was less likely among parents who reported that school/daycare requirements were a reason for vaccinating in the prior season (odd ratio [OR] = 0.17, 95% confidence interval [CI] = 0.05-0.55). Our findings suggest that school policies may improve vaccination rates among inconsistent vaccinators.

Health Insurance Navigation Tools Intervention: A Pilot Trial Within the Childhood Cancer Survivor Study.

PURPOSE: Childhood cancer survivors are at increased risk for underinsurance and health insurance-related financial burden. Interventions targeting health insurance literacy (HIL) to improve the ability to understand and use health insurance are needed. METHODS: We codeveloped a four-session health insurance navigation tools (HINT) intervention, delivered synchronously by a patient navigator, and a corresponding booklet. We conducted a randomized pilot trial with survivors from the Childhood Cancer Survivor Study comparing HINT with enhanced usual care (EUC; booklet). We assessed feasibility, acceptability, and preliminary efficacy (HIL, primary outcome; knowledge and confidence with health insurance terms and activity) on a 5-month survey and exit interviews. RESULTS: Among 231 invited, 82 (32.5%) survivors enrolled (53.7% female; median age 39 years, 75.6% had employer-sponsored insurance). Baseline HIL scores were low (mean = 28.5; 16-64; lower scores better); many lacked knowledge of Affordable Care Act (ACA) provisions. 80.5% completed four HINT sessions, and 93.9% completed the follow-up survey. Participants rated HINT's helpfulness a mean of 8.9 (0-10). Exit interviews confirmed HINT's acceptability, specifically its virtual and personalized delivery and helpfulness in building confidence in understanding one's coverage. Compared with EUC, HINT significantly improved HIL (effect size = 0.94. P < .001), ACA provisions knowledge (effect size = 0.73, P = .003), psychological financial hardship (effect size = 0.64, P < .006), and health insurance satisfaction (effect size = 0.55, P = .03). CONCLUSION: Results support the feasibility and acceptability of a virtual health insurance navigation program targeted for childhood survivors to improve HIL. Randomized trials to assess the efficacy and sustainability of health insurance navigation on HIL and financial burden are needed.

Vaccine Mandates and Influenza Vaccination During the Pandemic.

OBJECTIVES: To determine whether a state influenza vaccine mandate and elevated community coronavirus disease 2019 (COVID-19) severity affected a child's probability of receiving an influenza vaccine during the 2020-2021 influenza season, given the child's previous vaccination history. METHODS: Longitudinal cohort study using enrollment and claims data of 71 333 children aged 6 months to 18 years living in Massachusetts, New Hampshire, and Maine, from a regional insurer. Schoolchildren in Massachusetts were exposed to a new influenza vaccine mandate in the 2020-2021 season. Community COVID-19 severity was measured using county-level total cumulative confirmed case counts between March 2020 and August 2020 and linked by zip codes. The primary outcome of interest was a claim for any influenza vaccine in the 2020-2021 season. RESULTS: Children living in a state with a vaccine mandate during the 2020-2021 influenza season had a higher predicted probability of receiving an influenza vaccine than those living in states without a mandate (47.7%, confidence interval 46.4%-49.0%, vs 21.2%, confidence interval 18.8%-23.6%, respectively, for previous nonvaccinators, and 78.2%, confidence interval 77.4%-79.0%, vs 58.2%, confidence interval 54.7%-61.7%, for previous vaccinators); the difference was 6.5 percentage points greater among previous nonvaccinators (confidence interval 1.3%-11.7%). Previously vaccinated children had a lower predicted probability of receiving an influenza vaccine if they lived in a county with the highest COVID-19 severity compared with a county with low COVID-19 severity (72.1%, confidence interval 70.5%-73.7%, vs 77.3%, confidence interval 74.7%-79.9%). CONCLUSIONS: Strategies to improve uptake of influenza vaccination may have differential impact based on previous vaccination status and should account for community factors.

Vision Screening Among Children With Private Insurance: 2010-2019.

OBJECTIVES: To describe trends in vision screening based on insurance claims for young children in the United States. METHODS: This cross-sectional study used administrative claims data from the 2010-2019 IBM MarketScan Commercial Claims and Encounters Database. We included children aged 1 to <5 years at the beginning of each calendar year. The primary outcome was a vision screening claim within 12 months for chart-based or instrument-based screening. Linear regression was used to evaluate trends over time in vision screening claims and practitioner payment. RESULTS: This study included a median of 810 048 (interquartile range, 631 523 - 1 029 481) children between 2010 and 2019 (mean [standard deviation] age, 2.5 [1.1] years; 48.7% female). The percentage of children with vision screening claims increased from 16.7% in 2010 to 44.3% in 2019 (difference, 27.5%; 95% confidence interval, 27.4% to 27.7%). Instrument-based screening claims, which were identified in <0.2% of children in 2010, increased to 23.4% of children 1 to <3 years old and 14.4% of children 3 to <5 years old by 2019. From 2013 to 2018, the average of the median practitioner payment for instrument-based screening was $23.70, decreasing $2.10 per year during this time (95% confidence interval, $0.85 to $3.34; P = .009). CONCLUSIONS: Vision screening claims among young children nearly tripled over the last decade, and this change was driven by increased instrument-based screening for children aged <3 years. Further investigation is needed to determine whether the decreasing trends in practitioner payment for screening devices will reduce the adoption of vision screening technology in clinical practice.

Principles of Child Health Care Financing.

The American Academy of Pediatrics believes that the United States can and should ensure that all children, adolescents, and young adults from birth through the age of 26 years who reside within its borders have affordable access to high-quality comprehensive health care. Comprehensive, high-quality care addresses issues, challenges, and opportunities unique to children and young adults and addresses the effects of historic and present inequities. All families should have equitable access to professionals and facilities with expertise in the care of children within a reasonable distance of their residence. Payment methodologies should be structured to guarantee the economic viability of the pediatric medical home and of pediatric specialty and subspecialty practices. The recent increase in child uninsurance over the last several years is a threat to the well-being of children and families in the short- and long-term. Deficiencies in plans currently covering insured children pose similar threats. The AAP believes that the United States must not sacrifice recent hard-won gains for our children and that child health care financing should be based on the following guiding principles: (1) coverage with quality, affordable health insurance should be universal; (2) comprehensive pediatric services should be covered; (3) cost sharing should be affordable and should not negatively affect care; (4) payment should be adequate to strengthen family- and patient-centered medical homes; (5) child health financing policy should promote equity and address longstanding health and health care disparities; and (6) the unique characteristics and needs of children should be reflected.

Utilization and Spending With Preventive Drug Lists for Asthma Medications in High-Deductible Health Plans.

Importance: High-deductible health plans with health savings accounts (HDHP-HSAs) incentivize patients to use less health care, including necessary care. Preventive drug lists (PDLs) exempt high-value medications from the deductible, reducing out-of-pocket cost sharing; the associations of PDLs with health outcomes among patients with asthma is unknown. Objective: To evaluate the associations of a PDL for asthma medications on utilization, adverse outcomes, and patient spending for HDHP-HSA enrollees with asthma. Design, Setting, and Participants: This case-control study used matched groups of patients with asthma before and after an insurance design change using a national commercial health insurance claims data set from 2004-2017. Participants included patients aged 4 to 64 years enrolled for 1 year in an HDHP-HSA without a PDL in which asthma medications were subject to the deductible who then transitioned to an HDHP-HSA with a PDL that included asthma medications; these patients were compared with a matched weighted sample of patients with 2 years of continuous enrollment in an HDHP-HSA without a PDL. Models controlled for patient demographics and asthma severity and were stratified by neighborhood income. Analyses were conducted from October 2020 to June 2023. Exposures: Employer-mandated addition of a PDL that included asthma medications to an existing HDHP-HSA. Main Outcomes and Measures: Outcomes of interest were utilization of asthma medications on the PDL (controllers and albuterol), asthma exacerbations (oral steroid bursts and asthma-related emergency department use), and out-of-pocket spending (all and asthma-specific). Results: A total of 12 174 participants (mean [SD] age, 36.9 [16.9] years; 6848 [56.25%] female) were included in analyses. Compared with no PDL, PDLs were associated with increased rates of 30-day fills per enrollee for any controller medication (change, 0.10 [95% CI, 0.03 to 0.17] fills per enrollee; 12.9% increase) and for combination inhaled corticosteroid long-acting ß2-agonist (ICS-LABA) medications (change, 0.06 [95% CI, 0.01 to 0.10] fills per enrollee; 25.4% increase), and increased proportion of days covered with ICS-LABA (6.0% [0.7% to 11.3%] of days; 15.6% increase). Gaining a PDL was associated with decreased out-of-pocket spending on asthma care (change, -$34 [95% CI, -$47 to -$21] per enrollee; 28.4% difference), but there was no significant change in asthma exacerbations and no difference in results by income. Conclusions and Relevance: In this case-control study, reducing cost-sharing for asthma medications through a PDL was associated with increased adherence to controller medications, notably ICS-LABA medications used by patients with more severe asthma, but was not associated with improved clinical outcomes. These findings suggest that PDLs are a potential strategy to improve access and affordability of asthma care for patients in HDHP-HSAs.

"Pick a Plan and Roll the Dice": A qualitative study of consumer experiences selecting a health plan in the non-group market.

Background: For consumers without access to employer-sponsored or public insurance, health plan choices in the non-group (individual) insurance market that do not meet consumer needs have the potential for negative downstream implications for health and financial well-being. Objective: This qualitative interview study sought to understand consumers' experiences and challenges with choosing a non-group health plan, among those who later had negative experiences with the plan they chose. Methods: We conducted semi-structured telephone interviews with a purposive sample of 36 participants from a large regional health insurance carrier in three states who enrolled in non-group plans in 2017 (21 in Affordable Care Act (ACA) Marketplace plans and 15 enrolled off-Marketplace). Participants were included if they reported negative experiences using their plan after enrollment, such as higher-than-expected medical costs. Interviews explored challenges choosing a plan; information needed for choosing; usefulness of available tools; and preferred format for interventions to improve plan choice experiences. We analyzed interview transcripts using thematic content analysis. Results: Study participants reported experiencing substantial challenges to choosing an insurance plan. Key barriers included understanding insurance terms, finding relevant information, and making comparisons across plans. Participants valued the ability to make comparisons across carriers when using the Marketplace websites but were less satisfied with customer service. Suggestions for improvement included greater standardization of plans and language and availability of customized one-on-one assistance. Conclusion: Findings from this study suggest that health plan selection in the non-group market presents challenges to consumers that may be addressed through enrollment assistance and improved presentation of information. Personalized assistance to find and choose coverage may lead to plan choices that better meet consumer needs and increase confidence choosing a plan in subsequent enrollment periods.

Using Cost Conversations to Address Financial Toxicity in Pediatric Asthma Care: Findings From a Survey of Caregivers.

INTRODUCTION: Asthma care teams are well-positioned to help caregivers address financial toxicity in pediatric asthma care, although discussing cost can be challenging. We sought to characterize cost conversations in pediatric asthma specialty care. METHOD: We surveyed 45 caregivers of children aged 4-17 with asthma. Eligible caregivers reported costs concerns and had accompanied their child to a multisite asthma specialty practice in North Carolina. RESULTS: About one-third of caregivers reported a cost conversation (36%). Cost conversations were less common among caregivers whose child had public versus private health insurance (16% vs. 56%), who attended a telehealth versus in-person visit (6% vs. 52%), or who did not versus did want a conversation (19% vs. 77%, all p < .05). Common cost conversation topics were medications and equipment like spacers. DISCUSSION: Our findings suggest cost conversations may be relatively uncommon in pediatric asthma care, particularly for publicly insured patients and telehealth visits.

Delayed and forgone care for families with chronic conditions in high-deductible health plans.

BACKGROUND: High-deductible health plans (HDHPs) are an increasingly common strategy to contain health care costs. Individuals with chronic conditions are at particular risk for increased out-of-pocket costs in HDHPs and resulting cost-related underuse of essential health care. OBJECTIVE: To evaluate whether families with chronic conditions in HDHPs have higher rates of delayed or forgone care due to cost, compared with those in traditional health insurance plans. DESIGN: This mail and phone survey used multiple logistic regression to compare family-level rates of reporting delayed/forgone care in HDHPs vs. traditional plans. PARTICIPANTS: We selected families with children that had at least one member with a chronic condition. Families had employer-sponsored insurance in a Massachusetts health plan and >12 months of enrollment in an HDHP or a traditional plan. MAIN MEASURES: The primary outcome was report of any delayed or forgone care due to cost (acute care, emergency department visits, chronic care, checkups, or tests) for adults or children during the prior 12 months. RESULTS: Respondents included 208 families in HDHPs and 370 in traditional plans. Membership in an HDHP and lower income were each independently associated with higher probability of delayed/forgone care due to cost. For adult family members, the predicted probability of delayed/forgone care due to cost was higher in HDHPs than in traditional plans [40.0% vs 15.1% among families with incomes <400% of the federal poverty level (FPL) and 16.0% vs 4.8% among those with incomes ≥400% FPL]. Similar associations were observed for children. CONCLUSIONS: Among families with chronic conditions, reporting of delayed/forgone care due to cost is higher for both adults and children in HDHPs than in traditional plans. Families with lower incomes are also at higher risk for delayed/forgone care.

Affordability and Access Challenges Among US Subscribers to Nongroup Insurance Plans.

This cohort study assesses cost-related experiences in non-group plans purchased on or off Marketplace and variation by Marketplace enrollment, decision support use, and other characteristics.

Understanding Consumer Experiences and Insurance Outcomes Following Plan Disenrollment in the Nongroup Insurance Market.

Disenrollment from health plans purchased on Affordable Care Act (ACA) Marketplaces is frequent; little is known whether disenrollment from off-Marketplace plans is as common or about the experiences and consequences of disenrollment. Using longitudinal administrative data on 2017-2018 nongroup plan enrollment linked with survey data, we analyze plan disenrollment in one regional insurance carrier servicing three states. Overall, 71% of enrollees disenrolled from their 2017 plan. Disenrollment was associated with purchasing through an ACA Marketplace, the carrier making significant changes to an enrollee's plan benefit design, being healthier, being younger, and paying a higher premium for their 2017 plan in 2018. Experiencing financial burden or poor access to preferred providers was not associated with disenrollment. Most disenrollees (93.2%) enrolled in other coverage, often at a lower premium, but lacked confidence that they could afford needed care. These results can inform policy to support enrollees through coverage transitions and foster stability in the nongroup market.

Leveraging Telemedicine to Reduce the Financial Burden of Asthma Care.

One of the most compelling arguments for telemedicine is its potential to increase health care access by making care more affordable for patients and families, including those affected by asthma. This goal is critically important in the United States, where the high cost of asthma care is associated with nonadherence to preventive care regimens and suboptimal health outcomes. In this clinical commentary review, we draw from the literature and our own research to identify opportunities for and challenges to leveraging telemedicine to reduce the financial burden of asthma care. Our interviews with 42 families affected by asthma during the COVID-19 pandemic suggest that under favorable circumstances, telemedicine can meaningfully reduce costs, including those related to transportation and missed work, while offering high-quality care. However, families also identified ways in which telemedicine can increase costs. For example, some reported reduced access to support services and material resources such as medication samples, which they relied on to manage costs. In this way, our findings underscore the need for careful care coordination and communication in telemedicine. We conclude by discussing the 4Rs, a structured communication approach designed to support cost conversations, increase care coordination, and help families reduce asthma care cost burden.

Reliability of a patient survey assessing cost-related changes in health care use among high deductible health plan enrollees.

BACKGROUND: Recent increases in patient cost-sharing for health care have lent increasing importance to monitoring cost-related changes in health care use. Despite the widespread use of survey questions to measure changes in health care use and related behaviors, scant data exists on the reliability of such questions. METHODS: We administered a cross-sectional survey to a stratified random sample of families in a New England health plan's high deductible health plan (HDHP) with ≥ $500 in annualized out-of-pocket expenditures. Enrollees were asked about their knowledge of their plan, information seeking, behavior change associated with having a deductible, experience of delay in care due in part to cost, and hypothetical delay in care due in part to cost. Initial respondents were mailed a follow-up survey within two weeks of each family returning the original survey. We computed several agreement statistics to measure the test-retest reliability for select questions. We also conducted continuity adjusted chi-square, and McNemar tests in both the original and follow-up samples to measure the degree to which our results could be reproduced. Analyses were stratified by self-reported income. RESULTS: The test-retest reliability was moderate for the majority of questions (0.41 - 0.60) and the level of test-retest reliability did not differ substantially across each of the broader domains of questions. The observed proportions of respondents with delayed or foregone pediatric, adult, or any family care were similar when comparing the original and follow-up surveys. In the original survey, respondents in the lower-income group were more likely to delay or forego pediatric care, adult care, or any family care. All of the tests comparing income groups in the follow-up survey produced the same result as in the original survey. CONCLUSIONS: In this population of HDHP beneficiaries, we found that survey questions concerning plan knowledge, information seeking, and delayed or foregone care were moderately reliable. Our results offer reassurance for researchers using survey information to study the effects cost sharing on health care utilization.