Medicaid Spotlight: A $50 Billion Problem That Hits the Young and Poor the Hardest

Sep 16, 2013
More than 25 million people in the United States have asthma. Asthma attacks can life-threatening and lead to ER visits and hospitalizations. Each year, the direct medical cost of asthma is at least $50 billion, owing in part to nearly 775,000 annual ER visits by children under the age of 15.
  • Medicaid
  • Asthma
  • Children

The Problem

More than 25 million people in the United States have asthma,1 a condition characterized by shortness of breath, chest tightness, wheezing, coughing and other symptoms. Asthma attacks can be life threatening, often leading to emergency room (ER) visits and hospitalizations, particularly among children.2 Each year, the direct medical cost of asthma is at least $50 billion,3 owing in part to nearly 775,000 annual ER visits by children under the age of 15.4 Asthma also disproportionately impacts populations with low annual household incomes.5 Many low-income children and adults receive healthcare benefits through Medicaid, and some studies suggest that Medicaid patients with asthma have more attacks and use more healthcare resources than similar patients with private insurance or who are uninsured.6,7,8 Further, Medicaid patients are at an increased risk of low health literacy, which may further confound their ability to manage chronic conditions like asthma.9

Controller Meds Improve Outcomes

The number and severity of asthma attacks can be reduced through the regular use of asthma controller medications that work over time to reduce airway inflammation, decrease mucous production and desensitize the lungs to environmental triggers. These medications, which are indicated for preventive use on a long-term basis include inhaled corticosteroids, long-acting beta agonists and leukotriene modifiers. The National Institute of Health’s National Asthma Education and Prevention Program recommends daily use of one or more asthma controller medications,10 some of which require multiple treatments per day11 to reduce asthma symptoms and the number of attacks in both adults and children.12,13,14 Asthma controller medications also reduce ER visits and hospitalizations for asthma.15

It Takes a Village

Despite the success of asthma controller medications in preventing adverse outcomes, nonadherence to asthma medications is a known problem. Adherence rates vary by age and may be influenced by age-specific factors:

  • Preschool-age children have a limited ability to understand or communicate about medications. In addition, children of this age are often cared for by a variety of caregivers beyond their primary guardians. Both self-administration by very young children and shared responsibility for their medication taking pose challenges to adherence.16
  • Although responsibility for illness management and medication adherence increases with age,17 children’s knowledge about asthma and prevention of attacks tends to remain limited, presenting additional barriers to adherence.18
  • For adult asthma patients, nonadherence is also a challenge, but the related factors are different. A lack of understanding of the relationship between medication and health outcomes is a concern for some adult asthma patients,19 but adherence is also related to other factors such as access to care, length of therapy, length of experience with previous medications and the presence of a comorbid condition.20

Express Scripts Findings about Asthma Adherence

To measure adherence to asthma controller medications, Express Scripts researchers calculated medication possession ratios (MPRs) for Medicaid patients and patients with commercial insurance. MPR is a commonly used measure of adherence that is estimated by dividing the days’ supply of a medication that a patient has on hand by the number of days for which the medication should be available to that patient.

Across all age groups, adherence to asthma medications was low, as indicated by low MPRs for each group. In general, MPRs were higher in males than in females of the same age, and they increased with age. Among the youngest children aged 0-4 who resided in urban areas, MPR rates were higher than the rates seen for children residing in nonurban areas. However, in older children and in adults, higher MPRs were seen in nonurban patients. In urban and nonurban patients of both sexes and across age groups, MPRs for Medicaid beneficiaries were lower than those seen for their counterparts with commercial insurance. This presents additional challenges that compound those related to age.

Adherence to asthma controller medications can dramatically improve the quality of life for patients. Increased adherence to these medications may also help reduce the wasted healthcare dollars when beneficiaries with asthma avoid costly emergency room visits and hospitalizations. However, it is important to note that adherence rates differ by age, gender and geographic location. Long-term goals for asthma management should include better understanding of how factors such as age and income impact asthma medication adherence.


1 Akinbami LJ, Moorman JE, Bailey C, Zahran HS, et al. Trends in asthma prevalence, health care use and mortality in the United States, 2001-2010. NCHS data brief no. 94. Hyattsville, Md.: National Center for Health Statistics. 2012.

2 Johnston NW, Sears MR. Asthma attacks. 1: epidemiology. Thorax. 2006; 6: 722-728.

3 Barnett SB, Nurmagambetov TA. Costs of asthma in the United States: 2002-2007. J Allergy Clin Immunol. 2011; 127(1): 145-152.

4 American Lung Association. Asthma & children fact sheet. October 2012. Available at: Accessed January 4, 2013.

5 Aligne CA, Auinger P, Byrd RS, Weitzman M. Risk factors for pediatric asthma: contributions of poverty, race, and urban residence. Am J Respir Crit Care Med. 2000; 162(3 Pt 1): 873-877.

6 Finkelstein JA, Barton MB, Donahue JG, et al. Comparing asthma care for Medicaid and non-Medicaid children in a health maintenance organization. Arch Pediatr Adolesc Med. 2000; 154(6): 563-568.

7 Apter AJ, Reisine ST, Kennedy DG, Cromley EK, Keener J, ZuWallack RL. Demographic predictors of asthma treatment site: outpatient, inpatient or emergency department. Ann Allergy Asthma Immunol. 1997; 79(4): 353-361.

8 Griswold SK, Nordstrom CR, Clark S, et al. Asthma attacks in North American adults: who are the “frequent fliers” in the emergency department? Chest. 2005; 127(5): 1579-1986.

9 Kutner M, Greenberg E, Jin Y, Paulsen C. The health literacy of America’s adults: results from the 2003 National Assessment of Adult Literacy (NCES-2006-483). Washington, DC: US Department of Education. 2006. Available at: Accessed January 24, 2013.

10 National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3). Bethesda, Md.: National Institutes of Health. 2007. Available at: Accessed January 3, 2013.

11 Barnes PJ. Inhaled glucocorticoids for asthma. N Engl J Med. 1995; 332(13): 868-875.

12 van Essen-Zandvliet EE, Hughes MD, Waalkens HJ, et al. Effects of 22 months of treatment with inhaled corticosteroids and/or beta-2-agonists on lung function, airway responsiveness, and symptoms in children with asthma. Am Rev Respir Dis. 1992; 146(3): 547-554.

13 Suissa S, Ernst P, Benayoun S, Baltzan M, Cai B. Low-dose inhaled corticosteroids and the prevention of death from asthma. N Engl J Med. 2000; 343(5): 332-336.

14 Williams LK, Peterson EL, Wells K, et al. Quantifying the proportion of severe asthma attacks attributable to inhaled corticosteroid non-adherence. J Allergy Clin Immunol. 2011; 128(6): 1185-1191.

15 Adams RJ, Fuhlbrigge A, Finkelstein JA, et al. Impact of inhaled anti-inflammatory therapy on hospitalization and emergency department visits for children with asthma. Pediatrics. 2001; 107(4): 706-711.

16 Rand CS. Adherence to asthma therapy in the preschool child. Allergy. 2002; 57(S74): 48-57.

17 Orell-Valente JK, Jarlsberg LG, Hill LG, Cabana MD. At what age do children start taking daily asthma medications on their own? Pediatrics. 2008; 122(6): e1186-e1192.

18 McQuaid EL, Kopel SJ, Klein RB, Fritz GK. Medication adherence in pediatric asthma: reasoning, responsibility and behavior. J Pediatr Psychol. 2003; 38(5): 323-333.

19 Farber HJ, Capra AM, Finkelstein JA, et al. Misunderstanding of asthma controller medications: association with nonadherence. J Asthma. 2003; 40(1): 17-25.

20 Van Ganse E, Mork AC, Osman LM, et al. Factors affecting adherence to asthma treatment: patient and physician perspectives. Prim Care Respir J. 2003; 12(2): 46-51.

Author Bio

Lab Staff
comments powered by Disqus