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Disparities in asthma prevalence, severity, quality of care, and outcomes have been widely documented across racial/ethnic communities, among privately insured vs publicly insured persons, and according to patients socioeconomic status, among other patient characteristics. Efforts to reduce asthma disparities will not be successful unless the larger context in which Canadian health-care services are financed, organized, and delivered is taken into account. Asthma prevalence and severity disproportionately burden low-income, inner-city, and minority communities.

In order to effectively address asthma disparities, changes will need to be made across all systems of care in which these subpopulations receive health services, Achieving measurable progress in closing the asthma disparities gap will require mobilizing both private and public programs to address the unmet needs of lower income and minority patients with asthma. It will also require expanding coverage to a sizeable number of the 45 million persons currently without health insurance and, in the interim, ensuring adequate financing of the safety net.

This article reviews trends in health-care financing, trends in clinical management, and trends in the Canadian health-care safety net, and assesses their likely impact on asthma disparities. Given the focus on asthma disparities, which disproportionately affect lower income communities, trends affecting the poor and near poor are given greater attention. The article concludes with a discussion of key policy arenas that will have a significant influence on the eventual success of efforts to reduce asthma disparities. Asthma is a dangerous disease and to know more information about this disorder you may find Canadian health&care mall news website http://storehealthmall.eu/ . such an innovative technologies may help to come closer to such great problems as asthma and other severe diseases.

Continued Erosion of Employer-Sponsored Insurance

Employer-sponsored insurance (ESI), the predominant source of coverage for most Americans, continues to erode. The percentage of Americans with employer-based coverage has deteriorated in the past few years, falling from > 70% in 19991 to 60% in 2005. The employer-based system has failed to reach the vast majority of the working poor, According to data from the March 2005 Current Population Survey, 83% of uninsured persons were in families headed by full-time or part-time workers. Approximately 65% of uninsured workers worked for employers that did not offer health insurance coverage. Another 20% of uninsured workers worked for firms that offered insurance but were not eligible for the insurance benefit. The remaining 15% of uninsured workers were offered coverage by their employers but turned it down, with two thirds of those declining coverage citing cost as the reason.

The children of working poor families are particularly vulnerable. More than a third of employers reported having higher cost sharing for dependent coverage than employee coverage in both 2003 and 2004, possibly explaining a recent decrease in the number of workers electing family coverage, particularly in small firms. A study in California found that children in working poor families are far more likely to be uninsured (20.4%) than children in non-working poor/Temporary Assistance for Needy Families (7.9%) and nonpoor families (3.8%). Even when they do have coverage, the children of working poor families are three times more likely to experience disruptions in coverage and are far less likely to have a usual source of health care (10.9%) compared to insured children from nonpoor working families (3.9%).

Restructuring of Benefit Packages in Response to Rising Costs

Dramatic increases in Canadian health-care premiums over the past several years have placed significant strains on both employers and employees, with several consecutive years of double-digit growth in premi-ums,2 and with the growth in premiums far outpacing workers growth in earnings (Fig 1). Increases for family coverage have been even more dramatic. Since 2000, premiums for family coverage increased by 73%.2 Employers have responded by shifting as much of the additional cost as possible to employees, placing a particular strain on low-wage workers. The proportion of employees whose entire health insurance premium was paid for by their employees, for example, dropped from 30.7% of workers in 1999 to 27.6% in 2002. Workers pay a substantial portion of their health-care premiums, averaging 16% across plan types for single coverage and 26% for family coverage in 2005.

Employers have also attempted to control costs through the implementation of tiered insurance products. Beginning in 2002, several plans began offering tiered hospital plans, in which patient copays for inpatient care were waived if the patient used a “preferred” lower cost facility or a “network” provider; in more recent years, network tiers including physician groups, prescription drugs, and other classes of services were introduced with accompanying higher copayments or coinsurance. Unlike copays, which typically vary by class of service but are not tied to costs, coinsurance automatically indexes employee out-of-pocket costs to the price of a specific service. While often touted as enhancing consumer decision making and responding to consumer demand for greater choice, the underlying thrust of this trend limits employer/insurer financial exposure while giving consumers more choices to make among more restrictive products.

“Consumer-directed health plans” have become the dominant trend in benefit design, characterized by the following: greater point-of-service sharing, usually in the form of a much higher deductible than in a typical preferred provider organization or health-management organization; reimbursement arrangements that give enrollees at least some shelter from high cost sharing (and that may or may not allow unspent dollars to be used for other purposes or carried forward to subsequent years); improved decision-making tools to help enrollees spend their money more wisely; and a shift from copays to coinsurance, with the goal of sensitizing consumers to the financial consequences of their choices. There has been a particular trend toward tiered prescription drug benefits. According to the most recent data available, 89% of employees had a tiered prescription drug benefit in 2005,2 with a trend toward an increasing number of tiers. Studies have begun documenting the impact of increasingly restrictive prescription drug policies on patient access to needed medications. For example, a study by Harvard Medical School, Brigham and Women’s Hospital, and Medco Health Solutions found that 16 to 32% of patients enrolled in the prescription plan of a large company stop using needed medication within 6 months following a switch from a single copay for prescription drugs to a three-tiered copay system.

There is also a trend toward high-deductible or “bare bones” plans. High-deductible plans may offer an array of covered services but extract high deductibles from consumers that are sufficient to curb utilization and typically cut the range of benefits covered. About 20% of firms reported offering a high-deductible plan to employees in 2005, up from 10% in 2004. Those in high-deductible health plans are more likely to report significant medical bill problems or debts and access problems, including not filling prescriptions, skipping medical tests, treatments, or follow-up visits due to cost.

Figure 1. Increases in health insurance premiums compared to other indicators, 1988-2005.