As an allergist, I see some of the sickest asthmatics in our community. I see the ones that can barely function without using a rescue inhaler multiple times per day. I see those that are in the hospital multiple times per year with asthma exacerbations. I see those that are dependent on oral steroids to breathe. Do I see disparities in the prevalence of asthma- you bet I do!
The CDC recently published its first ‘CDC Health Disparities and Inequalities in the United States – 2011’. The data on asthma is not surprising. Overall prevalence of asthma was found to be 7.3% of the population – about 22 million people. Among adults, current asthma prevalence was higher among the multiracial (15.1%) and Puerto Rican Hispanics (12.8%) than among non-Hispanic blacks (7.8%) and non-Hispanic whites (7.7%) – nearly double. Women were nearly twice as likely to have asthma as men. This racial pattern is also seen among asthmatic children, with the exception that male children have higher rates of asthma prevalence than female children.
While some limitations to the data are inherent- such as problems with self-reporting of an asthma diagnosis and the data only being collected in English & Spanish, it is clear that minorities are affected by asthma more than others. What is to account for this disparity – socioeconomic status, increased environmental exposures, decreased access to care or provider biases in providing care?
In my clinical practice I see many asthmatics reside in suboptimal living situations. Miss K has dust mite and mold allergies that directly contribute to her asthma. She lives in a rental home that has old carpet and has a history of water intrusion with potential mold problems. Despite my avoidance instructions, the family of Miss K is limited- they can’t afford to move and break their lease. They are also in no position to pull up the carpet and lay down a hard surface. Their socioeconomic status is limiting their lifestyle choices which contribute to their child’s asthma.
I often find asthmatic patients have high co pays for medications or poor drug coverage. These patients make decisions to use their medications sparingly so the medications will last longer. Take Mrs. S as an example. She is an elderly, Hispanic woman on a fixed income. Her pharmacy plan requires her to pay over $100/month for her controller inhaler. While I supply her with samples whenever possible, many months go by where she uses her medication every 2-3 days. Personal pride keeps her from asking for more samples. This has led her to be hospitalized for asthma exacerbations and to use the ER for nighttime exacerbations that would have been prevented with daily controller medication usage.
I also find it amazing that I am only 1 of 2 allergists, in our area that offers care to Medicaid patients. This means that many patients drive >50miles for care and often wait months to get an appointment. This limited access to care surely impacts how early they get diagnosed, how aggressively they are treated and what treatments they are offered. Take Joey (not real name) – his mother had been trying to find an allergist to treat him for over 18months. During this time period he had 2 ICU admissions for near fatal asthma attacks and multiple ED visits for exacerbations. He had been only treated with as needed rescue inhalers. Finally, after his visit with us, we diagnosed him with allergic asthma and began him on Xolair (a novel immunomodulatory therapy for asthma). Since beginning this therapy, he has not been hospitalized nor had any ED visits.
So how do we address this disparity seen in asthmatics? The first step is to identify the disparity. We must then find ways to intervene. The ACA recognizes these disparities seen in many diseases like diabetes, hypertension and asthma. It also seems to understand the value in keeping people well rather than just treating sickness.
Attempting to insure all individuals will have a significant impact on minorities, those with chronic diseases and those in lower socioeconomic brackets. The Patient Protection and Affordable Care Act (PPACA) improves coverage by expanding Medicaid eligibility to up to 133% of the federal poverty level and by offering subsidies to families so they will be able to purchase insurance thru the state insurance exchanges (2014). In the interim, adult high risk pools (Pre-existing Condition Insurance Plan) have been set up to offer insurance to those that are currently ineligible due to chronic pre-existing conditions like asthma. For many asthmatics, this will bring them into the health care system offering them improved access to care.
Medicaid pilot programs, funded thru the PPACA, will assign enrollees with at least two chronic conditions to a medical health home – this will aid in better care of chronic conditions & appropriate referrals to specialists.
Community health centers currently provide care to populations that are disproportionately low-income and predominately uninsured or publicly insured. Most patients seeking care from the centers are members of a racial or ethnic minority group. Expanding funding to community health centers will specifically benefit these disenfranchised populations who have higher rates of asthma prevalence.
Helping close the donut-hole for Medicare beneficiaries will help people like Mrs. S afford their medications which in turn will allow them to be more compliant with important treatments.
There is so much more work to be done to help minimize the overall prevalence of asthma and specifically the racial and socioeconomic disparities noted. Doctors must be aware of biases that may affect the treatments we choose for our patients. We must acknowledge and identify socioeconomic factors that impact lifestyle decisions made by our patients. We must continue to fight for improved access to care, decreased cost of prescription medications, and the need for coordinated care of chronic diseases.
The PPACA moves us a few steps closer to reducing disparities in asthma and other chronic diseases.