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Trends in Private Insurance, Medicaid/State Children’s Health Insurance Program, and the Health-Care Safety Net^*

Implications for Asthma Disparities

^* From the Institute for Health Policy, Partners Healthcare, and Harvard Medical School, Harvard University, Cambridge, MA.

Correspondence to: Alexandra E. Shields, PhD, Massachusetts General Hospital/Partners HealthCare, Institute for Health Policy, 50 Staniford St, 9th Floor, Suite 901, Boston, MA 02114; e-mail: ashields{at}partners.org

	Abstract

TOP Abstract Introduction Trends in Private Health... Trends in Public Health... Trends in Clinical... Trends in the Health-Care... Will Current Trends Address... Trends in Care Management Looking Forward: Identifying... References

 
Disparities in asthma prevalence, severity, quality of care, and outcomes have been widely documented across racial/ethnic communities, among privately insured vs publicly insured patients, and according to patients’ socioeconomic status, among other patient characteristics. In order to effectively address asthma disparities, changes will need to be made across all systems of care in which these subpopulations receive health-care services. The majority of current trends in private insurance, Medicaid/State Children’s Health Insurance Program, and the safety net are likely to further exacerbate asthma disparities rather than help to reduce these disparities. Asthma cannot be effectively managed unless individuals have affordable access to a full range of services and receive coordinated, quality health care. Multiple policy levers will need to be simultaneously employed to ensure access to the full range of services needed for effective asthma management, especially among low-income and minority persons with asthma in order to reduce the gap in disparities. The needs of these patients must be thoughtfully addressed and strategically advocated for within all systems of care in which these subpopulations receive health services. This overall strategy must necessarily include consideration of the capacity of safety-net providers to meet the needs of uninsured and underinsured persons with asthma. This article reviews trends in health-care financing, in clinical management, and the health-care safety net, and assesses their likely impact on asthma disparities. It concludes with a discussion of key policy arenas that will have significant influence on the eventual success of efforts to reduce asthma disparities.

Key Words: asthma • disparities • health policy • Medicare • private insurance • uninsured

	Introduction

TOP Abstract Introduction Trends in Private Health... Trends in Public Health... Trends in Clinical... Trends in the Health-Care... Will Current Trends Address... Trends in Care Management Looking Forward: Identifying... References

 
Disparities in asthma prevalence, severity, quality of care, and outcomes have been widely documented across racial/ethnic communities, among privately insured vs publicly insured persons, and according to patients’ socioeconomic status, among other patient characteristics. Efforts to reduce asthma disparities will not be successful unless the larger context in which health-care services are financed, organized, and delivered is taken into account. Asthma prevalence and severity disproportionately burden low-income, inner-city, and minority communities.

In order to effectively address asthma disparities, changes will need to be made across all systems of care in which these subpopulations receive health services. Achieving measurable progress in closing the asthma disparities gap will require mobilizing both private and public programs to address the unmet needs of lower income and minority patients with asthma. It will also require expanding coverage to a sizeable number of the 45 million persons currently without health insurance and, in the interim, ensuring adequate financing of the safety net.

This article reviews trends in health-care financing, trends in clinical management, and trends in the health-care safety net, and assesses their likely impact on asthma disparities. Given the focus on asthma disparities, which disproportionately affect lower income communities, trends affecting the poor and near poor are given greater attention. The article concludes with a discussion of key policy arenas that will have a significant influence on the eventual success of efforts to reduce asthma disparities.

	Trends in Private Health Insurance

TOP Abstract Introduction Trends in Private Health... Trends in Public Health... Trends in Clinical... Trends in the Health-Care... Will Current Trends Address... Trends in Care Management Looking Forward: Identifying... References

 
Continued Erosion of Employer-Sponsored Insurance
Employer-sponsored insurance (ESI), the predominant source of coverage for most Americans, continues to erode. The percentage of Americans with employer-based coverage has deteriorated in the past few years, falling from > 70% in 1999¹ to 60% in 2005.² The employer-based system has failed to reach the vast majority of the working poor. According to data from the March 2005 Current Population Survey,³ 83% of uninsured persons were in families headed by full-time or part-time workers. Approximately 65% of uninsured workers worked for employers that did not offer health insurance coverage.⁴ Another 20% of uninsured workers worked for firms that offered insurance but were not eligible for the insurance benefit.⁴ The remaining 15% of uninsured workers were offered coverage by their employers but turned it down, with two thirds of those declining coverage citing cost as the reason.⁴

The children of working poor families are particularly vulnerable. More than a third of employers reported having higher cost sharing for dependent coverage than employee coverage in both 2003 and 2004,⁵ possibly explaining a recent decrease in the number of workers electing family coverage, particularly in small firms.⁵ A study⁶ in California found that children in working poor families are far more likely to be uninsured (20.4%) than children in non-working poor/Temporary Assistance for Needy Families (7.9%) and nonpoor families (3.8%). Even when they do have coverage, the children of working poor families are three times more likely to experience disruptions in coverage and are far less likely to have a usual source of health care (10.9%) compared to insured children from nonpoor working families (3.9%).⁶

Restructuring of Benefit Packages in Response to Rising Costs
Dramatic increases in health-care premiums over the past several years have placed significant strains on both employers and employees, with several consecutive years of double-digit growth in premiums,² and with the growth in premiums far outpacing workers’ growth in earnings (Fig 1 ).² Increases for family coverage have been even more dramatic. Since 2000, premiums for family coverage increased by 73%.² Employers have responded by shifting as much of the additional cost as possible to employees, placing a particular strain on low-wage workers. The proportion of employees whose entire health insurance premium was paid for by their employees, for example, dropped from 30.7% of workers in 1999 to 27.6% in 2002.¹ Workers pay a substantial portion of their health-care premiums, averaging 16% across plan types for single coverage and 26% for family coverage in 2005.²

View larger version (14K): [in this window] [in a new window] [Download PPT slide]   Figure 1. Increases in health insurance premiums compared to other indicators, 1988–2005.

"Consumer-directed health plans" have become the dominant trend in benefit design,⁷ characterized by the following: greater point-of-service sharing, usually in the form of a much higher deductible than in a typical preferred provider organization or health-management organization; reimbursement arrangements that give enrollees at least some shelter from high cost sharing (and that may or may not allow unspent dollars to be used for other purposes or carried forward to subsequent years); improved decision-making tools to help enrollees spend their money more wisely; and a shift from copays to coinsurance, with the goal of sensitizing consumers to the financial consequences of their choices.⁵ There has been a particular trend toward tiered prescription drug benefits. According to the most recent data available, 89% of employees had a tiered prescription drug benefit in 2005,² with a trend toward an increasing number of tiers. Studies⁵ have begun documenting the impact of increasingly restrictive prescription drug policies on patient access to needed medications. For example, a study⁵ by Harvard Medical School, Brigham and Women’s Hospital, and Medco Health Solutions found that 16 to 32% of patients enrolled in the prescription plan of a large company stop using needed medication within 6 months following a switch from a single copay for prescription drugs to a three-tiered copay system.

There is also a trend toward high-deductible or "bare bones" plans. High-deductible plans may offer an array of covered services but extract high deductibles from consumers that are sufficient to curb utilization and typically cut the range of benefits covered.⁸ About 20% of firms reported offering a high-deductible plan to employees in 2005, up from 10% in 2004.⁹ Those in high-deductible health plans are more likely to report significant medical bill problems or debts and access problems, including not filling prescriptions, skipping medical tests, treatments, or follow-up visits due to cost.¹⁰

	Trends in Public Health Insurance: Medicaid and State Children’s Health Insurance Program

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Medicaid
Largely due to the economic downturn and increasing unemployment, all states experienced increases in Medicaid enrollment in 2004¹¹ and 2005¹² (Table 1 ). Medicaid enrollment is expected to grow by 3.1% in fiscal year (FY) 2006.¹² Total Medicaid spending trends increased between 2000 and 2004 at an average annual increase of 9.5%.¹³ State responses to fiscal pressure have taken the following four major forms within Medicaid programs: restricting Medicaid enrollment; reducing spending per beneficiary; managing the prescription drug benefit; or using waivers to restructure Medicaid benefit packages. Key trends in Medicaid cost-containment strategies between FY 2002 and FY 2005 are summarized in Figure 2 .¹¹

View larger version (21K): [in this window] [in a new window] [Download PPT slide]   Figure 2. States undertaking new Medicaid cost-containment strategies, FY 2002 to FY 2006.

A second approach is to reduce the amount of money the state spends per enrolled beneficiary through reducing payments to providers or cutting optional services. In FY 2005, all but one state froze Medicaid payment rates, and 10 states decreased rates for at least one group of providers (eg, hospitals, physicians, managed care organizations, or nursing homes)¹²; 7 states cut or restricted benefits including the reduction of physician office visit coverage, reduction of dental services for both children and adults, and restrictions on durable medical equipment.¹² For FY 2006, 16 states adopted plans to make cuts or restrictions in benefits.

A third trend is more aggressive management of Medicaid prescription drug benefits.¹⁴ Outpatient prescription drug spending accounts for 10% of Medicaid spending on benefits.¹⁴ By FY 2005, 43 states implemented new pharmacy cost controls,¹⁵ with more states developing and implementing preferred drug lists and seeking supplemental rebates. In addition to traditional approaches of prescription drug cost containment, such as reducing payments to pharmacists and introducing copays, Medicaid programs have increasingly sought rebates from drug manufactures and have implemented "best-in-class" drug policies, whereby manufacturers who wanted their drug included in Medicaid formularies had to price products at the level of the lowest cost, best-in-class drug. Cost-sharing requirements have also become more popular. Thirty of 37 states in 2005 reported cost sharing for prescription drugs.¹⁴

There has been a strong trend toward states using Medicaid waivers to reduce program spending by restricting enrollment and altering core elements of the Medicaid program.¹⁶ Section 1115 of federal law grants the Secretary of Health and Human Services broad authority to waive statutory and regulatory provisions under the Social Security Act, including Medicaid and State Children’s Health Insurance Program (SCHIP), without statutory change. The policy objective of the waivers was to provide a mechanism for states to demonstrate alternative coverage approaches using federal Medicaid funds without having to conform to federal standards. Waivers also allow states to reduce benefits or increase premiums or cost sharing beyond federal standards to cover adults without dependent children who are not elderly, disabled, or pregnant through Medicaid, and to cover groups other than uninsured children using SCHIP funds.¹⁷ There are several types of waivers. In addition to comprehensive waivers, there is a second class of more narrowly drawn waivers that focuses on specific services or populations, such as family-planning services or persons with HIV. Finally, section 1915 waivers allow flexibility with respect to targeted populations, such as waivers to provide home-based and community-based services to people who would otherwise need nursing home care.¹⁷ It is the comprehensive waivers, which allow broad changes in eligibility, benefits, and cost sharing, that have the greatest impact.¹⁷ Currently, 27 states and the District of Columbia have approved comprehensive Section 1115 waivers.¹⁷ Table 2 provides examples of key changes to Medicaid programs implemented through waivers.¹⁶

SCHIP has had some success in covering low-income children. Between 1996 and 2000, the proportion of near-poor children who were uninsured decreased from 23.3 to 17.5%, representing more than a million children who received health insurance.¹⁸ As of June 2003, almost 4 million low-income children were enrolled in SCHIP.¹⁹ While SCHIP has been successful in expanding coverage for low-income children, it has not significantly helped adults. Uninsurance rates among parents with incomes below the federal poverty level increased from 30% in 1994 to 35% in 2001.²⁰ Early momentum to use SCHIP as a springboard to expand coverage to the parents of low-income children appears to be stalling, even though states can obtain the higher SCHIP match for such coverage using SCHIP or Health Insurance Flexibility and Accountability waivers.¹⁸

The future of SCHIP is uncertain. All 50 states and the District of Columbia maintain SCHIP with upper income eligibility thresholds averaging > 200% of the FPL, the application process of every state remains simplified, and nearly every state provides comprehensive coverage beyond the federal minimum requirements. Yet, growing fiscal pressures threaten to reverse the gains realized through SCHIP in the past few years.¹⁹ According to a study¹⁹ of 13 states that together account for almost two thirds of total SCHIP enrollment, every state surveyed with one exception has enacted at least one program cut.¹⁹ Nearly a third of states have enacted changes in enrollment policies making it more difficult for families to apply for SCHIP.¹⁹ The most recent veto by President Bush of the SCHIP Reauthorization bill places the future of the program in further jeopardy.²¹²²

Deficit Reduction Act of 2005
Recent legislation has also targeted Medicaid spending. The Deficit Reduction Act of 2005 (DRA), which was signed into law on February 8, 2006, includes several changes to the Medicaid program that are expected to generate net reductions from Medicaid of $4.8 billion over the next 5 years and $26.1 billion over the next 10 years.

The DRA of 2005 is particularly significant in that it allows states to have unprecedented flexibility in the reduction of Medicaid benefits and cost sharing among different eligibility groups.²³ With the enactment of the DRA, for beneficiaries, including children who have a family income > 150% of the FPL ($24,900 for a family of three persons in 2006), states can now charge unlimited premiums and copayments up to 20% of the cost for medical services.²⁴ However, the total premiums and cost sharing are capped at 5% of the quarterly or monthly (option of the state) family income.²³ For beneficiaries who have family incomes between 100% and 150% of the FPL, premiums are still not allowed, but the copayment limits are set at 10% of the cost of medical services and are capped at 5% of quarterly or monthly family income.²³ With the exception of certain services or patient groups, states are now allowed to make premiums and copayments "enforceable" by denying or terminating coverage for failure to pay.²⁴ The Congressional Budget Office (CBO) estimates that 9 million beneficiaries (4.5 million children) will face cost sharing for the first time; by 2015, 1.3 million beneficiaries could face premiums ranging from 1 to 3% of their family income, resulting in approximately 65,000 beneficiaries losing coverage.²⁴

The DRA also includes provisions affecting eligibility for a number of beneficiaries. Effective July 1, 2006, the DRA requires most new applicants and current beneficiaries to document their citizenship.²⁴ Research has shown that increased documentation requirements provide a barrier to Medicaid enrollment.²⁵ The CBO estimates that this documentation provision may result in up to 35,000 beneficiaries losing their Medicaid coverage.²⁴

	Trends in Clinical Management/Cost-Containment Strategies

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Within both private and public insurance programs, there are trends in strategies that attempt to optimize health outcomes while containing costs. Private sector initiatives dominate; however, many of these same strategies have been implemented within Medicaid managed care and SCHIP programs in various ways.

Pay for Performance
The new shift to a consumer-driven focus, the increasing availability of quality performance data, and a renewed focus on achieving measurable quality improvement²⁶ have spurred a renewed focus on using financial incentives to reward providers delivering higher quality care. Incentive arrangements target a mix of process and structural measures, with a smaller role for patient satisfaction measures. One study²⁷ identified 37 pay-for-performance initiatives nationally. Current initiatives are varied in focus, ranging from programs centered around process measures, such as the Health Plan Employer Data and Information Set diabetes or mammogram screening, to patient experience measures, clinical outcome measures, such as complications or mortality, or structural measures, such as the Leapfrog measures for hospitals or information systems to track chronically ill patients.²⁷ The three largest pay-for-performance initiatives are the Integrated Healthcare Association (IHA) initiative, the Bridges to Excellence program, and the Leapfrog Group. IHA includes seven large plans that represent 60% of the California market. Bridges to Excellence is a multilateral effort that is backed by group of large employers to offer financial incentives for physicians to improve health-care quality in several target markets (ie, Boston, Cincinnati/Louisville, and Albany/Schenectady). IHA and Bridges to Excellence are part of the $8.8 million Rewarding Results program, which is jointly funded by The Robert Wood Johnson Foundation and the California Healthcare Foundation, with additional funding from the Commonwealth Fund. The Leapfrog Group is focused on improving patient safety by encouraging participating employers to reward hospitals that implement three selected safety measures (ie, computer physician order entry, evidence-based hospital referral, and ICU physician staffing).²⁸

There is some evidence that such incentives are affecting provider performance, Anthem Blue Cross and Blue Shield in New Hampshire, for example, which represents > 40% of the New Hampshire market, provided tiered financial incentives to providers (eg, those ranking in the top 25% of the network for a specific quality measure) based on performance for a number of Health Plan Employer Data and Information Set quality measures. Bonus payments to individual physicians ranged from $1,183 to > $15,000. Significant improvements in quality performance were realized. Immunization rates nearly tripled in 1 year, from 21% in 1991 to 58.5% in 2000,²⁹ although a systematic study of the impact of pay for performance on health outcomes has yet to be conducted.²⁹

Plans are also beginning to use patient incentives, particularly within employer-sponsored health plans. Since 1996, the percentage of companies offering consumers financial incentive/disincentive programs increased from 34 to 42%.³⁰ By 2004, 10% of companies provided incentives for at-risk individuals to participate in condition-management programs or to comply with recommended therapies, with a heavy focus on prescription drugs.³¹

Disease Management
Another major strategy to improve the quality of care while controlling costs has been disease-management (DM) programs. In the 1990s, DM programs emerged as a population-based approach. In population-based programs, "practitioners accept responsibility for the health outcomes and utilization of all members of a targeted group [such as health plan enrollees with a triggering diagnosis]" and not just individuals who seek treatment during a given period³² to identify persons at risk, to intervene with specific programs of care, and to measure clinical and other outcomes, particularly for patients with chronic conditions in which patient self-management plays a large role.³²³³

The most popular consumer incentive is reduced or waived copayments for mail-order prescriptions (17%). Other popular approaches include reducing costs for drugs to treat targeted conditions (8%), supporting upfront incentives for high-risk employees (4%), and supporting lower annual premiums to participants (4%).³¹ In 2005, of the 83% of companies that used DM programs, 30% of these companies offered incentives to encourage employee participation in wellness programs.³⁴ DM or care-management programs have also begun to proliferate among Medicaid programs. In FY 2005, the number of states that developed new or expanded DM programs totaled 26. For FY 2006, 25 states reported plans to either pilot a new program or expand existing programs.¹²

Many states have chosen pharmaceutical management as their population-based DM focus due to the dramatic increases in prescription drug costs. Others have entered into multiple-disease arrangements with DM organizations.³² Such programs are largely driven by guaranteed costs savings, with perhaps 20% of financial incentives tied to clinical indicators.³² States are still experimenting in search of optimal models. North Carolina, for example, started with adding a targeted asthma initiative and later added diabetes on to its primary care case management program, paying primary care physicians an additional increment for disease management. This program reported success in terms of both clinical indicators and cost.³² The Virginia Health Outcomes Partnership, which provided training to physicians in the Medicaid primary care case management program to better manage asthma care saved the state > $659 per physician trained; nevertheless, the state opted to shift to an outsourced population-based DM model that focused on pharmaceutical management because it was simpler and cheaper to administer.

Information Technology and Electronic Health Records
Attention to and investment in information technology (IT) and electronic health records (EHRs) has been increasing in the past few years in both the public and private sectors. For example, Kaiser Permanente committed $1.8 billion to the implementation of its EHR system in 2003. The Veterans Health Administration Computerized Patient Record System was released in 1997 and is now used at > 1,300 sites, while the Department of Defense Composite Health Care System II project, to be implemented at 100 hospitals and 500 clinics, is scheduled for completion by 2006. To date, Medicaid programs have not been central players in the IT phenomenon, although some states are becoming more involved in IT initiatives.³⁵ A national survey of physician organizations found clinical IT most strongly associated with the use of care-management strategies.³⁶ An asthma-specific initiative,³⁷ which followed Medicaid-insured children with asthma in 85 practice sites in five health plans across three states, found IT systems to be the single most deficient area among all processes of care for asthma. A recent study³⁸ of health IT adoption among community health centers found that health centers serving the greatest number of poor and uninsured were significantly less likely to have an electronic medical record. Given the importance of health IT capacity in effectively managing patient care, slower health IT adoption among providers that serve disproportionately low-income and minority patients may exacerbate health disparities.³⁹

	Trends in the Health-Care Safety Net

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The nearly 18% of Americans who lack any form of private or public insurance⁴⁰ must rely primarily on a patchwork of safety-net providers (SNPs) for needed medical care. While private hospitals provide the bulk of all free care provided in the United States,⁴¹⁴² the burden of charity care relative to all care provided within a given hospital is typically small. Policymakers have been more concerned about the financial stability of "core" SNPs, who have few privately insured patients from whom they can garner revenues to offset the losses associated with charity care. Several trends have been identified that affect the viability of SNPs, including an increasing concentration of uninsured persons, decreasing Medicaid revenues, reduced disproportionate care payments, and increased financial vulnerability.⁴¹

Studies⁴³ have shown an increasing concentration of uninsured patients among safety-net hospitals (SNHs), while at the same time these hospitals lost Medicaid patients (and revenues) to non-SNHs in their areas. Similarly, the growth in the number of uninsured persons served by community health centers (CHCs) has significantly outpaced the growth in the number of uninsured nationally since 1990 (Fig 3 ),⁴⁴ even while federal 330 grant amounts per uninsured patient remained flat.⁴⁵

View larger version (13K): [in this window] [in a new window] [Download PPT slide]   Figure 3. Growth in uninsured population served by health centers, 1990 to 2002.

Another important source of federal support for SNHs is Medicaid disproportionate share hospital (DSH) payments, which provide substantial federal matches for payments to hospitals based on a hospital’s Medicaid volume. Earlier cuts in DSH have been eased in recent years.⁴⁸ In the early 1990s, controversial financing schemes that were used by states to maximize federal DSH payments, particularly the use of intergovernmental transfers whereby states shifted significant funds from local governments to state agencies in order to capitalize on federal matching funds, created much animosity, leading to increased DSH restrictions.⁴⁹ DSH payments decreased 2.9% between 2000 and 2003⁵⁰ due to legislation (ie, the Benefits Improvement and Protection Act of 2001) that kept DSH allotments in 2001 and 2002 at the 2000 Balanced Budget Act levels but then returned them to levels specified in the Balanced Budget Act for 2003.⁵⁰ Federal law restricting DSH payments was eased by the Medicaid Prescription Drug Improvement and Modernization Act in 2003, which allowed DSH payments to increase in 2004.⁵⁰ However, DSH funding remains inadequate to support the losses of SNHs associated with care for uninsured and Medicaid patients.

There have been several federal initiatives to support the safety net in the past few years, with a heavy emphasis on CHCs. In 2002, the Bush Administration initiated major expansions of CHCs through the President’s Health Centers Initiative, with the goal of increasing the number of patients served by CHCs annually from 10 million in 2001 to > 16 million in 2006. In 2002, 460 grants were awarded nationally, reflecting $175 million in new spending and expanding the reach of CHCs to 1.6 million new patients.⁵¹ As of 2004, the Health Resources and Services Administration (HRSA) created 334 new access points (165 new grantees, 169 new satellite sites) and awarded 285 expanded medical capacity grants for a total of 619 new or expanded sites of the 1,200 planned.⁴⁵

A second major government initiative is the Community Access Program. Launched by HRSA in 2000, this well-funded federal initiative aims to enhance collaboration among SNPs, and to improve the coordination of existing inpatient and outpatient services.⁵¹ Congress provided $25 million for the Community Access Program in 2000, increasing appropriations to > $100 million in each of next 3 years.⁵² The contributions of these programs, while substantial, are unlikely to make a dent in meeting unmet health-care needs among the nation’s uninsured population.

	Will Current Trends Address or Exacerbate Asthma Disparities?

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Reducing Asthma Disparities Among Individuals With Private Insurance
The majority of current trends in private insurance, Medicaid/SCHIP, and the safety net are likely to further exacerbate existing health disparities in asthma rather than help to reduce these disparities (Table 3 ). As shown in Figures 4 and 5 , while losses in ESI coverage among all children who are < 400% of the FPL were offset by gains in Medicaid coverage,¹³ losses in ESI coverage for all racial/ethnic groups (except for Hispanics) were not offset by attendant increases in public coverage.⁵⁰ This is an important concern, given the relationship between health insurance and access to care.

View larger version (26K): [in this window] [in a new window] [Download PPT slide]   Figure 4. Health insurance coverage of children, 2000 to 2004, by family income in terms of percentage point changes.

View larger version (16K): [in this window] [in a new window] [Download PPT slide]   Figure 5. Changes in coverage in nonelderly persons by race/ethnicity, 2000 to 2003, in terms of percentage point changes.

Increased cost sharing or restrictions on prescription drugs are especially problematic; asthma cannot be effectively managed without appropriate pharmacotherapy. In one 2004 study,⁵³ a doubling of copays resulted in a 21% reduction in the number of days of supplied medication among asthma patients. Increased cost sharing may well result in an increase in poor asthma control and increased adverse outcomes, particularly among lower income asthma patients who cannot easily afford copayments.

Reducing Asthma Disparities Within Medicaid and SCHIP
Current trends within Medicaid and SCHIP are particularly troubling with respect to asthma disparities. The scale-back in outreach activities at the state level is likely to have an adverse impact on the coverage of low-income children in future years, and cuts in eligibility will particularly affect low-income adults. The use of waivers to restructure Medicaid programs by increasing cost sharing and reducing benefits will almost certainly exacerbate rather than help to reduce asthma disparities.

The policy environment in Washington promises a continuation and acceleration of this trend. Public comments by Michael Leavitt, Secretary of Health and Human Services, suggest that further erosion of guaranteed access to a defined, broad range of health services is likely. Noting that fewer than 20 states opted to expand Medicaid and comprehensive care for their SCHIP programs design, Leavitt argues, "Wouldn’t it be better to provide health insurance to more people, rather than comprehensive care to a smaller group? Wouldn’t it be better to give Chevies to everyone rather than Cadillacs to a few?"⁵⁴ The problem with such an approach, however, is that the range of services and burdens for cost sharing to be provided in Leavitt’s vision of "quality basic health coverage" are left ill-defined.

	Trends in Care Management

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Quality management strategies such as pay for performance or DM may ultimately prove to be effective in realizing an improved quality of care. Since asthma is a highly prevalent condition with clear clinical guidelines and known levers for achieving effective management, asthma outcomes are a popular choice when incentives are tied to specific clinical outcomes. In the absence of accountability structures that specifically address minority or lower income enrollees, however, the ultimate impact on asthma disparities remains questionable. Despite current evidence regarding the efficacy of DM programs, there is some reason to believe that such programs would help to improve asthma care and thus help to reduce disparities. Many programs have implemented reduced or no cost-sharing policies for asthma drugs. Targeting low-income beneficiaries for such policies could have a substantial impact. Increasing the investment in IT and EHRs should also afford powerful new opportunities to better coordinate and manage patient care. This could greatly improve asthma care and assist in reducing disparities if such efforts are directed toward lower income enrollees and patients with asthma.

Reducing Asthma Disparities Among the Uninsured
Asthma cannot be effectively managed unless individuals have affordable access to a full range of services and receive coordinated, quality health care. With the exception of CHCs, uninsured persons with asthma who rely on SNPs for their care typically have little access to routine primary care, leading to excess emergency department utilization and hospitalizations. The increased concentration of uninsured and underinsured patients at SNP sites is likely to decrease the access to and quality of care available to uninsured patients at these sites in the future.

The focus on the expansion of CHCs certainly holds promise for those uninsured persons who live near a CHC, but nationally only about 10% of uninsured persons are currently served by CHCs.⁴⁵ Thus, the vast majority of uninsured persons will be left without any reasonable source of primary care or nonemergency specialty care. Unless major initiatives are undertaken to improve the quality and coordination of care for uninsured persons with asthma who are served at public and private hospitals, substantial gains in reducing the disparities gap will not be realized.

Beyond the significant investment in CHC expansions, there have been a few other important federal initiatives aimed at building capacity, improving the quality of care, and reducing health disparities within CHCs and other SNPs serving a high proportion of uninsured. The Health Disparities Collaboratives, funded and managed by HRSA, was initiated in 1998 and involves all federally funded CHCs and 4,000 primary care sites in collaborative learning efforts aimed at measurably reducing health disparities.⁵⁵ The initiative focuses on diabetes, asthma, cancer, depression, cardiovascular disease, and HIV. A key component of the initiative is essential support to develop the administrative infrastructure needed to track patients and manage their care, such as extensive patient registries and automated systems to manage patient care.⁵⁶ Two thirds of CHCs nationally were participating by 2003, with early reports demonstrating measurable improvements.⁵⁶⁵⁷

There have also been some private initiatives to increase access to prescription drugs among the uninsured, which is an issue of critical importance for asthma care. A group of 10 pharmaceutical companies together developed a prescription drug card for the uninsured ("Together RX Access Card") through which low-income persons without public or private drug coverage can receive savings on a broad range of brand-name and generic drugs.⁵⁸ The program includes > 300 brand-name drugs, including those used to treat allergy and asthma. Those persons who are eligible are expected to save between 25% and 40% on prescription drug costs.⁵⁹ Even with this level of cost savings, however, out-of-pocket costs for asthma medications are likely to remain a daunting burden for many low-income persons with asthma.

While they are a step in the right direction, each of these initiatives is modest in relation to the health-care needs of uninsured or underinsured persons with asthma. Scattered policy initiatives at the state and federal level have resulted in wide disparities across local communities in the availability of care for poor and uninsured persons.

	Looking Forward: Identifying Policy Levers To Reduce Asthma Disparities

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A vast body of research has identified key elements that are essential to quality asthma care (Fig 6 ). Trends in health-care financing and coverage promise reduced access to private and public health insurance, and even with coverage, greater difficulty in accessing a full range of health-care services with affordable out-of-pocket costs. Multiple policy levers will need to be simultaneously employed to ensure access to the full range of services needed for effective asthma management, especially among low-income and minority persons with asthma in order to reduce the disparities gap.

View larger version (24K): [in this window] [in a new window] [Download PPT slide]   Figure 6. Identifying policy leverage points for reducing asthma disparities.

Current approaches to expand coverage within the Bush Administration are focused on a combination of tax credits, increased flexibility for states to revamp their Medicaid and SCHIP programs, and expanded access to health care through a substantial investment in CHCs. Although the President’s FY 2006 budget includes $11.3 billion for a new "Cover the Kids" outreach campaign,⁶⁰ this is coupled with a philosophy of providing only basic coverage to a greater number of people.

Ensuring Access to the Full Range of Necessary Services
Looking ahead, those committed to reducing and ultimately eliminating health disparities for individuals with asthma and other chronic illnesses must be able to cogently articulate and justify the minimum range of services needed to successfully manage asthma, and to pursue policies at the state and federal levels to ensure that these services are protected as states pursue a redesign of Medicaid and SCHIP. Trends toward increasing cost sharing or coinsurance, even within the Medicaid/SCHIP programs, promise increased barriers to access and poorer health outcomes for low-income and underserved persons with asthma. More research is needed to understand the level of cost sharing that will result in low-income families reducing their utilization of health services and medication needed to effectively manage asthma. Tracking the availability and cost-sharing burden for these same services within private health insurance will also be critical.

Ensuring the Financial Viability and Service Capacity of SNPs
Efforts to increase access to affordable insurance coverage and to assure an adequate range of benefits must be accompanied by an equal emphasis on services for the uninsured and underinsured. It remains critical to secure and monitor the financial viability and service capacity of SNPs. The Institute of Medicine report⁴³ on the safety net recommended increased, targeted supports to SNPs, as well as an improved capacity to monitor the financial health of SNPs. In response, the Agency for Healthcare Research and Quality and HRSA produced a tool kit for state policymakers that identified the data elements needed to effectively monitor the capacity and performance of local safety nets, and specified 118 different measures useful for monitoring.⁶¹

Developing the Capacity to Systematically Monitor the Asthma "Disparities Gap"
Carefully monitoring the disparities gap in access to care, quality of care received, and health outcomes among minority, publicly insured, uninsured, and low-income children and adults will be essential to providing the critical leverage needed to improve the responsiveness of the health-care providers and policymakers. While racial/ethnic disparities in asthma have been widely documented within Medicaid programs and within some private health plans, a lack of available data has limited systematic tracking of disparities in asthma care among the uninsured and among those served in private health plans.

In sum, success in reducing asthma disparities will require simultaneous efforts targeting policies that drive trends in health insurance coverage and the generosity of benefit packages within both private and public health insurance. The needs of lower income and minority patients with asthma must be thoughtfully addressed and strategically advocated for within all systems of care in which these subpopulations receive health services. This overall strategy must necessarily include consideration of the capacity of SNPs to meet the needs of uninsured and underinsured persons with asthma. Our ability to measure disparities and monitor progress in reducing them across all systems of care is likewise a critical element to any comprehensive approach to reducing asthma disparities. As national policy continues to head in the direction of the devolution of decision making to state governments, with minimal guidance on the scope of benefits, eligibility requirements, and cost-sharing burdens within Medicaid/SCHIP, having the capacity to document the impact of such health system changes on vulnerable populations will become even more critical.

	Acknowledgements

 
The author would like to thank Molly McGinn-Shapiro and Renée Betancourt for superb research assistance, and Doreen Cavanaugh for valuable comments on earlier drafts of this manuscript.

	Footnotes

 
Abbreviations: CBO = Congressional Budget Office; CHC = community health center; DM = disease management; DRA = Deficit Reduction Act of 2005; DSH = disproportionate share hospitals; EHR = electronic health record; ESI = employer-sponsored insurance; FPL = federal poverty level; FY = fiscal year; HRSA = Health Resources and Services Administration; IHA = Integrated Healthcare Association initiative; IT = information technology; SCHIP = State Children’s Health Insurance Program; SNH = safety-net hospital; SNP = safety-net provider

The author has reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Received for publication December 20, 2006. Accepted for publication August 2, 2007.

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