Association of Asthma Management and Insurance Type Among Children in the United States

In the United States asthma is a leading chronic illness among young children and adolescents. According to Joseph et al. (1996) low-income children may represent the large proportion of undiagnosed asthma cases. Asthma creates a burden on racial and ethnic minorities and low-income children.

Health insurance appears to contribute to continuity of asthma services. Minority children may be particularly vulnerable to asthma complications since over half are from households that are poor or near poor and 35% respectively have no health insurance. Medicaid is a program in the United States that is jointly funded by state and federal government to provide health care services to individuals who typically meet certain low-income criteria. Medicaid-eligible children are more likely to be minority, vulnerable, and suffer poor outcomes from asthma.

According to Bratton et al. (2006) Medicaid insured children with asthma are less likely to receive health care services within the recommended national guidelines. The more frequent use of the emergency department and inpatient services for asthma by African American children insured by Medicaid can not fully be explained by poverty or inadequate health insurance. Among economically and socially marginalized groups, the higher prevalence of asthma may be explained through the complex etiology involving social and environmental factors, but wide speculation continues regarding racial disparities among children with asthma.

Prior studies have indicated that asthma not only increases health care use and places a burden on asthmatic children and their families, but asthma related medical expenditures are estimated at $465 million for children age 0-17 and the costs continue to rise.13 Adults and children combined costs associated with asthma is estimated at $6.2 billion dollars annually.14 The total costs of care for children age one to seventeen with asthma totaled $1129 per year, compared to $468 for children without asthma.13 Pediatric asthma related expenditures were twenty-four percent higher in African-American children at $436 versus $350 per child annually. Annual costs for inpatient treatment of asthma in the pediatric population are estimated at $41.8 billion with emergency services consuming an additional $480 million.

The National Institute's of Health, National Heart, Lung, and Blood Institute (NHLBI) created recommendations to encourage physicians to provide guidelines to improve the home management of asthma exacerbations to all asthma patients, which included having a written asthma action plan with information on what to do at home, when to call the clinician, and when to seek emergency care.18 The plan provides the individual with asthma and their family procedures on how to use preventive medications, emergency medications, the peak flow meter, and when to seek health care and emergency care.

Medicaid-insured children with asthma experience several barriers related to income and insurance limitations.21 Barriers to asthma care that are specific to Medicaid-insured children include differences in asthma care from health care providers and lack of continuity of care due to Medicaid insurance status. Even within the Medicaid populations, minority children experience a disproportionate burden. Even within the Medicaid populations, minority children experience a disproportionate burden. In a study conducted by Lieu et al. (2002) within the same managed Medicaid group Black and Latino children had worse asthma status and less use of preventive asthma medications than White children. Toward that end, Medicaid-insured children with asthma can improve overall health status regardless of race and health insurance status if attention is given to practice organization, standardized protocols, and preventive measures. This study analyzed insurance type and the relationship between having an asthma management plan among children with asthma across all races in the United States.

METHODS

Study Variables. This study is a secondary data analysis of the 2002 and 2003 National Health Interview Survey.25 The independent variables are age, race, gender, parental income, region, parental education, health status, health care utilization, source of health care, and health insurance coverage, and the outcome variables are asthma management plan status and asthmatic episodes. The outcome variable asthma management is defined by the question in the National Health Interview Survey (Has a doctor or other health professional ever given the child an asthma management plan?). The other outcome variable, asthmatic episodes, is defined as number of episodes within last 12 months. Additional variables of interest include: advised to change environment for asthma, ever taken preventive asthma medications, respiratory therapist's visits, and emergency department visit due to asthma.

Data Management. The data was initially processed with Statistical Analysis Software 8.2.26 The data was further analyzed using SAS callable SUDAAN to account for the complex multistage sampling design of the National Health Interview Survey.27 A final combined data set was created from each individual year of data that was merged. If the response to a question included, “Don't Know or Refused” responses were set to missing. Institutional Review Board exemption from the University of South Carolina has been granted.

Statistical Data Analysis. Parametric testing using Univariate/Bivariate/Multivariate analysis was performed to examine asthma management plan physician recommendations among children in the United States. Frequency distributions and univariate statistics were measured to describe the population (PROC FREQ in SAS). The chi square test statistic was used to test for independence between age, race, gender, income, region, parental education, health status, health care utilization, health insurance coverage, and asthma management plan status. Distribution of variables according to age, race, gender, income, region, parental education, health status, health care utilization, health insurance coverage, and asthma management plan status are presented with p-values and proportions with 95% confidence intervals (CI) and odds ratios (OR).

The bivariate statistics provided the first indication of the differences and associations between the variables. Multivariate analysis for each outcome variable was used to adjust for other demographic factors and dichotomous variables. The estimates produced in this study will be weighted to present the United States population and to adjust for potential survey response bias. For all analysis statistical significance was set at P<.05.

RESULTS

Using SAS, descriptive statistics were obtained from the National Health Interview data on 0-17 year old children with asthma in the United States. The 2002 and 2003 original weighted sample population consisted of approximately 13,000 children, and a subset of the data were conducted to account for the 3,102 children identified as having asthma based on the question in the survey (Has a doctor or other health professional ever told you that your child has asthma?) and then a follow-up question (Does your child still have asthma?) led to a final study population of 2,110 children.

The study population included Hispanic (22.92%), Non-Hispanic White (50.96%), and Non-Hispanic Black (26.12%) children. The gender distribution of the children was male (57.11%), and female (42.89%). The percentage of children under five years of age was (28.90%), and for children five to seventeen years of age was (71.10%).

Among the children in the sample population participants identified their family income as $65,000 and over (29.58%), $45,000-$64,999 (14.82%), $25,000-$44,999 (24.56%), and $15,000-$24,999 (14.08%), $01-$14,999 (16.96%). Among all racial groups the highest level of income for Whites was $65,000 and over (40.54%), Blacks was $01-$14,000 (27.07%), and Hispanics was $25,000-$44,999 (31.48%).

The majority of the parents in this study identified their highest level of education as a high school graduate/GED recipient, Mom (29.01%), and Dad (30.28%). The proportion of the study population that was located in the Northeast region was (21.23%), Midwest (22.70%), South (36.30%), and West (19.76%). The percentage of children with asthma that had private insurance was (53.59%), Medicaid (25.49%), CHIP (4.90%), Tricare (1.76%), and Uninsured (6.85%). The majority of the study participants reported not having an asthma management plan at (59.00%).

Among the children in this study the majority of them had seen a general doctor in the past twelve months (87.93%). The percentage of children with asthma in this study that had an asthma episode in the past twelve months was (62.42%). Those who reported ever taken preventive asthma medications were (57.19%). Half of the participants in this study at (50.96%) reported being advised to change their environment due to their asthma.

In the bivariate analysis children that had private insurance were less likely to have an asthma management plan (OR=.72, p=.0012). Statistical significance was found among children that reported having CHIP being twice as likely to have an asthma management plan (OR=2.42, p=.0007). In the multivariate analysis Whites were significantly more likely than to have an asthma management plan (OR=1.66, p=.0031). Children with private insurance remained less likely to have an asthma management plan. In this study children who reported CHIP coverage were twice as likely to have an asthma management plan (OR=2.28, p=.0066).

Marginal statistical significance was found among children that had seen a general doctor in the past twelve months being more likely to report having an asthma management plan (OR=1.41, p=.0831). In this study children who reported CHIP coverage were twice as likely to have an asthma management plan (OR=2.28, p=.0066). In this study, children who had been advised to change their environment due to their asthma condition was less likely to have an asthma management plan (OR=.32, p<.0001). Children who were taking preventive asthma medications were significantly less likely to have an asthma management plan (OR=.22, p<.0001). In this study, children who had an asthma episode in the past twelve months were less likely to have an asthma management plan (OR=.62, p=.0002).

DISCUSSION

Findings from this study indicate that Black and Hispanic children with asthma

are less likely to have an asthma management plan. Statistical significance was

not found among children with CHIP being more likely to have an asthma management

plan than privately insured children. In particular, children who reported having CHIP

coverage were twice as likely to have an asthma management plan. In the multivariate

analysis children who reported CHIP coverage remained twice as likely to have an

asthma management plan (OR=2.28, p=.0066). Surprisingly, in this study children who

had private insurance were less likely to have an asthma management plan.

The explanation for the interesting findings regarding insurance type and asthma

management plan status are unclear, as the opposite trend is usually observed. Public

health insurance programs may be gaining more widespread acceptance by private

practitioners in the United States, which may have lead to the children insured by CHIP

being more likely to have an asthma management plan.11 Having private insurance did

not result in higher rates of having an asthma management plan as expected, however

children with private insurance possibly are healthier overall than children that have

public insurance. These findings indicate that health insurance type is a predictor in

physician recommended asthma management plans.

The use of National Health Interview Survey provided a large nationally representative sample, along with the accuracy and reliability of the National Health Interview Survey is a major strength of this study. The use of SUDAAN for all data analysis increased the preciseness and validity of the study results.

Potential limitations of the study are that it is limited based on its reliance solely on parental reporting of the asthma status of the child without analyzing medical records, which could lead to a potential over-estimation on under-estimation bias. Better assessment of asthma management plan recommendations and type of health insurance for children with asthma will have to be considered in the future.

Despite the many medical milestones and accomplishments of the American medical system, there is still disproportionate amount of health disparities that still exist, and this issue is a major health policy priority. Mandating all insurers provide an asthma management plan to children with asthma may reduce the race-based inequities and differences in insurance type in having an asthma management plan. The findings from this study warrant further investigation into the practices of physicians in recommending an asthma management plan.

Methods to convince primary care providers to embrace management efforts to control asthma are essential. The gap has to be closed regarding known practices to reduce negative outcomes among children with asthma and what is actually done in practice. It is important to continue research on asthma disparities and develop sustainable interventions to increase asthma management plan recommendations.