Don’t Hold Your Breath: The Effect of the Affordable Care Act on Pediatric Asthma

Abstract

This thesis examines the effect of the Patient Protection and Affordable Care Act (ACA) on pediatric asthma in the United States. Asthma is the most common pediatric chronic disease and is a leading cause of emergency department (ED) visits, hospitalizations, and missed school days among children in the US. While there is no cure for asthma, the disease can be effectively managed with medication and avoidance of asthma triggers, such as dust, mold, and airborne allergens. The goal of asthma management is to reduce the burden of symptoms and to prevent acute asthma exacerbations, commonly referred to as asthma attacks. However, numerous barriers impede proper asthma management, leading to poorly controlled asthma and high rates of utilization of costly ED- and hospital-based services for treatment. With the passage of the ACA in 2010, the US healthcare system underwent its most significant reform in decades. This thesis focuses on the impact of three provisions of the ACA that have the potential to lead to improvements in the treatment of pediatric asthma. Specifically, the three provisions are (1) the expansion of Medicaid, (2) increasing Medicaid reimbursement rates for primary care physicians, and (3) changing Medicaid reimbursement regulations to allow Medicaid funds to be expended for services provided by non-licensed healthcare providers, such as community health workers. Using ED and hospital utilization data from California as a case study, this thesis analyzes the effects of these changes. Contrary to the hypotheses proposed here, the changes introduced in the ACA have thus far failed to spark improvements in asthma management. In California, the rate of asthma-related pediatric ED visits and hospitalizations increased for children with Medicaid and racial disparities in asthma outcomes have widened—two outcomes for which the opposite results were anticipated. This thesis offers several explanations for these results. While more previously uninsured children have been enrolled in Medicaid, barriers to accessing primary care and poor home environments continue to impede proper asthma management. Increasing Medicaid reimbursement rates for primary care physicians aimed to address access concerns, but the reform’s temporary nature, delays in the rollout of this change, and the difficulties associated with payment reform for managed care organizations together presented barriers to improving physician access. And while in-home visits by community health workers to provide asthma education and environmental interventions have been shown to be effective at improving asthma management, legislative, administrative, and practical barriers prevented a rapid proliferation of home-based intervention programs and improved asthma outcomes. Finally, this thesis looks ahead to how improved implementation of these reforms along with additional proposed solutions at the clinical and policy levels can help make highquality asthma care available, accessible, and affordable.