After age 18, asthma care deteriorates

In what may be the first study to measure health care utilization patterns among young adults with chronic health problems—in this case asthma—a team of researchers at Harvard Medical School found that losing health insurance was a significant predictor of deteriorating patterns of health management. Other social factors, including leaving school and losing adult supervision, also contributed to the deterioration.

“This study suggests that expanding insurance coverage will help many young adults with asthma receive the care that they need,” said Kao-Ping Chua, a staff physician in the Division of Emergency Medicine at Boston Children's Hospital who led the study. “But it also points to the importance of addressing other socially-mediated factors in this population.”

J. Michael McWilliams, HMS assistant professor of health care policy and medicine at Brigham and Women's Hospital was the senior author of the study, to be published April 22 in Pediatrics.

“Aside from the lack of financial protection, uninsurance poses fewer health risks to young adults than for older adults because they are generally healthy,” McWilliams said. “But for young people with asthma—or other conditions amenable to medical care—it's important to understand and address the barriers to care.”

The researchers used nationally representative data from the 1999 to 2009 Medical Expenditure Panel Survey, looking at a sample of 2,485 individuals between the ages of 14 and 25. The researchers investigated how an individual's age related to having a regular care provider, visiting that provider at least once per year, using asthma medications, and visiting the emergency room.

They found that while adolescents under age 18 were more likely to utilize primary care and preventive measures, young adults over age 18 were more likely to use the emergency room and have problems accessing medical care and medications because of cost. Losing insurance explained 32 percent of the decline in use of primary care and 47 to 61 percent of the increase in cost-related access problems.

Under the federal Affordable Care Act health reform law, young people whose parents have private insurance will be eligible to remain covered on their parents' policies until they are 26. The news is not so good for many low-income young people whose parents may be uninsured or receive public assistance. Since the Supreme Court ruled that the ACA could not require states to expand their Medicaid coverage, many states have decided not to expand coverage, and one of the key groups that will likely be left out is low-income young adults.

“We may continue to see particularly poor asthma care for many young adults in states that don't expand their Medicaid programs,” McWilliams said.

But increasing insurance coverage alone is not the answer, the researchers said. Health professionals who provide care for children and adolescents with chronic illnesses like asthma have to think about patients who are aging out of their practice, the researchers said.

“Young people with asthma need to work with their care providers to create transition plans from pediatric to adult care that take into account their medical and social history,” Chua said.

This research was supported by the Harvard Pediatric Health Services Research Fellowship (AHRQ NRSA 5T32HS00063-17), the Beeson Career Development Award Program (National Institute on Aging K08 AG038354 and the American Federation for Aging Research) and Doris Duke Charitable Foundation (Clinical Scientist Development Award #2010053).

Written by Jake Miller

Harvard Medical School has more than 7,500 full-time faculty working in 11 academic departments located at the School's Boston campus or in one of 47 hospital-based clinical departments at 16 Harvard-affiliated teaching hospitals and research institutes. Those affiliates include Beth Israel Deaconess Medical Center, Brigham and Women's Hospital, Cambridge Health Alliance, Boston Children's Hospital, Dana-Farber Cancer Institute, Harvard Pilgrim Health Care, Hebrew SeniorLife, Joslin Diabetes Center, Judge Baker Children's Center, Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital, McLean Hospital, Mount Auburn Hospital, Schepens Eye Research Institute, Spaulding Rehabilitation Hospital, and VA Boston Healthcare System.