Asthma is a serious chronic disease impacting quality of life and health outcomes for about 6 million children in the U.S. While childhood asthma can be effectively managed for most kids, the Centers for Disease Control and Prevention estimates about 44% of children currently have uncontrolled asthma, placing them at greater risk for asthma attacks, hospitalizations and missed school days. According to the CDC, asthma costs about $50 billion per year in health care costs, with emergency department visits and asthma attacks higher among people with lower incomes.
In addition to higher prevalence among low-income children, childhood asthma is significantly more common among Black and American Indian/Alaska Native children, and Black people are significantly more likely to die from asthma than any other racial or ethnic group. There are many factors contributing to childhood asthma disparities, including barriers to accessing primary care and prescribed medications, and environmental factors such as greater exposure to poor indoor and outdoor air quality. These socioeconomic, racial and ethnic disparities emphasize the need for multifaceted asthma management approaches that are tailored to the unique needs and conditions of individual children and families.
The National Asthma Education and Prevention Program, also known as the NAEPP, was created by the National Health, Lung and Blood Institute to establish national guidelines for the treatment of asthma. The goals of the NAEPP are to raise public awareness regarding the seriousness of asthma, teach people to identify its signs and symptoms, and enhance the quality of life for people with the disease. The NAEPP develops guidelines and tools for patients and clinicians, including recommendations for reducing the impacts of asthma through well-developed treatment and action plans and guides for initial diagnosis and ongoing follow-up.
The CDC’s National Asthma Control Program was established to reduce deaths, hospital visits and the economic impacts of uncontrolled asthma. The agency has also developed collaborative initiatives such as EXHALE and the 6|18 Initiative to educate children and their families, public health professionals, Medicaid officials and policymakers about evidence-based strategies to improve asthma management.
The strategies and interventions identified in the NAEPP guidelines and the CDC’s initiatives and described throughout this article have been shown to improve asthma control and medication adherence while reducing ED visits, hospitalizations, and missed work or school days. According to NAEPP guidelines, asthma management models with the greatest impact are coordinated and comprehensive, using a combination of health care services and non-medical services such as asthma education, social supports and community-based strategies.
State Policy Options
Most states have established asthma prevention and control programs and statewide asthma action plans incorporating NAEPP guidelines and CDC strategies to develop effective models for managing childhood asthma. States are implementing and considering various policy options to build on these current programs to provide more comprehensive access to medical and non-medical services that improve health outcomes and decrease health disparities for childhood asthma.
Health Care Services and Insurance Coverage
Primary care is often the initial intervention helping children access first-line asthma medications and treatments, receive asthma action plans and get referrals to other services. Most children with asthma have health insurance coverage, and Medicaid coverage may help reduce asthma disparities as low-income children with asthma are more likely than low-income kids without the disease to have Medicaid coverage. Medicaid and private insurers cover asthma medications and devices, with Medicaid providing comprehensive health services to children through the program’s Early, Periodic, Screening, Diagnostic and Treatment benefit.
With most children covered by public or private insurance, state policymakers have options to improve primary care effectiveness, thereby improving asthma management and outcomes. States can use patient-centered medical homes and Medicaid health homes, which provide person-centered care to manage chronic conditions and focus on connections to social supports. These models include payment incentives to better coordinate whole-person care across primary care, school and other settings using teams of primary care physicians, nurses, social workers and other professionals. For example, Kansas has implemented a health home specifically serving Medicaid beneficiaries with asthma who are at risk for other chronic conditions. The program offers care coordination and case management, family supports and other services. States choosing the health home option may access enhanced federal matching funds of 90% for the first 10 quarters of operation.
Another policy option states can consider is reducing or eliminating utilization controls that create barriers to accessing primary care services. Some Medicaid programs and private insurance plans impose utilization controls, including benefit limits, prior authorization requirements and copayments, that can affect the ability to access medications and devices. Evidence indicates that higher copayment costs impacted use of asthma treatments and hospitalizations.
Home visiting services are a proven strategy to better manage asthma and improve quality of life for children with asthma. Such services are delivered by nurses or certified asthma education professionals to provide self-management education, review asthma action plans and medication use. Asthma self-management education helps children and their families learn how to use medications and devices correctly and manage their asthma action plans. Home visits can also include assessments of the home to identify and mitigate exposure to asthma triggers including dust, mold and pests.
To build sustainable home visiting programs, some states provide Medicaid reimbursement for the service for children at high risk for asthma attacks or other signs of uncontrolled asthma. For example, Missouri established Medicaid reimbursement for home visits with limited hours of asthma education and two asthma environmental assessments per year. Massachusetts and California cover home visits in their Medicaid programs, and cover the cost of supplies to reduce environmental triggers (high-efficiency vacuums and air filters, mite-proof mattress covers, etc.) and manage pest problems. In a study of children receiving home visiting and mitigation services in Boston, the Massachusetts health department found improvements in health outcomes, reductions of home environmental triggers and demonstrated Medicaid cost savings.
While there has been much emphasis on identifying and reducing asthma triggers at home, the COVID-19 pandemic emphasized the need for broader strategies. As respiratory viruses exacerbate asthma symptoms and attacks, COVID was expected increase asthma attacks; however, attacks and emergency department visits declined during the pandemic. Some of that decrease can be attributed to COVID mitigation strategies that reduced exposure to other respiratory diseases; but, with schools closed, many children were no longer exposed to such triggers as school bus diesel fumes, harsh cleaning products or other potential environmental irritants.
State policymakers can establish standards and policies to improve school environments to reduce airborne triggers. Several states, including Connecticut, Indiana, Massachusetts and Mississippi, require schools to have indoor air-quality management policies and regular inspections of HVAC systems along with standards for carpeting, cleaning products and HEPA filters. Illinois and North Carolina limit school bus idling time to reduce the amount of diesel fumes released into the air. Additionally, many states require smoke-free campuses and tobacco prevention education.
State policymakers can require schools to have specific procedures regarding access to medication, emergency protocols and nurse-to-student ratios. All 50 states have laws ensuring students have the right to carry and administer their prescribed albuterol medication. For students who do not have their inhalers with them in an emergency, some states have laws or official guidelines allowing schools to stock and administer prescribed albuterol.
Schools are also a critical access point for medical services, particularly for low-income children who are more likely to be enrolled in Medicaid. A federal policy change in 2014 provided states with the option to allow Medicaid reimbursement for health care services provided in schools for all eligible children, eliminating the so-called free care rule. As of March 2022, 17 states had expanded their Medicaid reimbursement of health care services, including asthma management, in schools, and several states are working to implement this reimbursement policy option.
Asthma is one of the most common chronic conditions impacting children’s health and quality of life, and it can be effectively managed with access to appropriate services. States continue to build on existing asthma control programs to improve access to comprehensive services to better control asthma and reduce poor outcomes and health disparities. Using NAEPP guidelines and CDC technical support and assistance, policymakers can refine their asthma strategic plans to effectively implement programs that best meet the unique needs of children in their states.
Emily Blanford is a program principal in NCSL’s Health Program.