A few months ago in the emergency department, I saw a child who had been getting only half as many puffs of their asthma controller medication as prescribed. The mother, hoping to make the $185 inhaler last longer, figured some medicine was better than none. For many people, living on the financial edge, life is a series of trade-offs – medicine vs food vs clothing vs transportation – that most of us are completely unfamiliar with.
Health insurance is supposed to minimize the need to include medical care as part of that zero-sum equation. The Affordable Care Act, by expanding coverage, should therefore increase access to care. But one of the changes that has accompanied the ACA is a huge increase in cost-sharing, not just for people covered by policies acquired through the ACA, but for everyone. Over 20% of all health plans now are high deductible plans, and they are growing far faster than any other type of coverage. We are now starting to see some of the effects of this shift of financial responsibility for health costs away from insurers and toward patients. Back in the 1970s, the RAND Health Insurance Experiment randomized people to high vs. low deductible plans. Their main findings were that those who had to pay higher out-of-pocket costs used less medical services, both necessary and unnecessary, and that overall there was no demonstrable difference in health outcomes. Many have since latched onto this as evidence that cost sharing can decrease spending without harming health. But dig into the details and you’d see that among those people with lower incomes and poorer health to start with, there were adverse effects of greater cost sharing (specifically, higher mortality among those with hypertension).
In the July issue of JAMA Pediatrics, researchers from Boston report on the effect of cost sharing on children with asthma. Similar to the RAND study, forgoing needed care (including medications and emergency department visits) was more common among those families with higher cost sharing who were also below 250% of the federal poverty level. Moreover, such families reported worse asthma control. They also were more likely to have to borrow money (33.3%) or defer other necessities (17.6%) than families who either had less cost sharing in their health insurance, or higher family income.
At present, children covered under Medicaid have very little cost sharing. Indeed, in the JAMA Pediatrics study, children covered by Medicaid fared reasonably well. However, those families who have employer-provided insurance, or those obtaining coverage via the public exchanges, may well fall into that combination of modest income and high cost sharing that leads to forgoing needed care for their children. We as health care providers need to be aware of the kinds of Sophie’s choices they are faced with. How can we support them? We can ask them if they are having trouble making ends meet, if they are having to trade off food for medication. We can be sensitive to the cost of the care we provide, and consider less expensive alternatives when appropriate. And we can be non-judgmental when we find out they missed a clinic visit, or didn’t refill a prescription. Instead, we can be curious.