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Kahn PA, Daggula KR, Teng W, Hintz RC, Berland G. Medical Exemption From Disconnection of Utilities in Connecticut. JAMA. 2020;323(12):1189–1190. doi:10.1001/jama.2020.0542
For patients with health conditions that require electricity for device use or prescription refrigeration, public utilities offer protection from disconnection with physician certification, with policies varying by state. In Connecticut, utilities are prohibited from disconnecting service to those with a life-threatening illness as certified by a physician,1 with definition of “life-threatening” left to the physician’s judgment. Although the association between energy insecurity and health outcomes has been studied in children, less is known about the association in adults with more complex health needs.2,3 We examined trends in medical exemptions from utility disconnection in Connecticut and the characteristics and health care use of adults applying for exemptions in a large primary care practice.
For the examination of trends, data were obtained from the Connecticut Public Utilities Regulatory Authority (PURA) Docket 18-04-254 for the 2 power companies that deliver electricity in the state. The number of households with medical exemptions and their outstanding balance in the first (2011) and last (2017) years reported to PURA were compared. Charges still accrue when medical exemptions are in place; outstanding balance refers to the accumulated amount owed to the utilities, including charges accrued that cannot be collected during the exemption.
For the examination of adults applying for exemptions, approval was obtained from the Yale University institutional review board, which waived the need for informed consent. Data were collected from Yale New Haven Hospital electronic health records for 2015 through 2018 for patients who submitted exemption requests to primary care physicians at the largest primary care center. We abstracted age, sex, race, insurance status, body mass index, and primary language. We characterized the number of hospital and emergency department visits and diagnoses commonly requiring electric-powered devices for treatment, including asthma, congestive heart failure, chronic obstructive pulmonary disease, diabetes, and end-stage kidney disease. Prescriptions for insulin and dialysis, if present on the current medication or problem list, were excerpted. Comparison data were obtained from the remaining primary care center patients. Data were analyzed using Tableau 2019.1 (Tableau Software) and SPSS version 26 (IBM). Pearson χ2 or t tests were used, with P < .05 (2-tailed) defining statistical significance.
The number of households with medical exemptions increased from 5191 in December 2011 to 6936 in December 2017 for one electricity supplier and declined from 33 053 to 24 942 for the other. Both utilities reported increases in outstanding balances, from $26 356 000 in 2011 to $41 802 000 in 2017 for one utility and from $21 201 383 to $43 655 465 for the other. Combined, 31 878 households had medical protection from utility disconnection in 2017; the uncollected amount in these accounts was $85 457 465.
Of 12 610 primary care patients, 724 (5.7%) applied for medical utility exemptions. They were more likely than those without exemption to be older, female, English-speaking, and black, and to have asthma, diabetes, end-stage kidney disease, chronic obstructive pulmonary disease, and congestive heart failure, but did not differ on insurance status. Dialysis was more common for those with medical exemptions, while insulin use was less common. The mean number of hospitalizations for the study population in 2015-2018 was 7.5 vs 2.8 in the overall population (difference, 4.6 [95% CI, 3.7-5.6]; P < .001). The mean number of emergency department visits was 16.5 vs 8.6 in the overall population (difference, 7.9 [95% CI, 6.4-9.5]; P < .001) (Table).
For the major electricity suppliers in Connecticut in 2017, the cumulative balance owed by households with medical exemptions was $85.5 million—larger than the $78.7 million total amount provided by the federally funded Low Income Home Energy Assistance Program to Connecticut consumers to assist with energy bills in 2017.5 Individuals applying for medical utility assistance had more medical needs, including respiratory diagnoses and non–insulin-dependent diabetes, that may require electricity for device use.
Limitations include restriction to a single state and no information on health outcomes. Because medical exemptions are of limited duration, it is unknown if some of the health care utilization occurred during periods when utilities were disconnected. Evidence that these programs prevent harm or exacerbation of illness is understudied6; studies examining the association between medical utility protection and health outcomes are needed.
Accepted for Publication: January 14, 2020.
Corresponding Author: Peter A. Kahn, MD, MPH, ThM, Yale University School of Medicine, 20 York St, Tompkins 209, New Haven, CT 06504 (email@example.com).
Author Contributions: Mr Daggula and Dr Teng had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Kahn, Berland.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Kahn.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Kahn, Teng, Berland.
Administrative, technical, or material support: Kahn, Daggula, Hintz, Berland.
Supervision: Kahn, Berland.
Conflict of Interest Disclosures: None reported.
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