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Original Investigation
May 10, 2021

Controller Medication Use and Exacerbations for Children and Adults With Asthma in High-Deductible Health Plans

Author Affiliations
  • 1Harvard Pilgrim Health Care Institute, Department of Population Medicine, Harvard Medical School, Boston, Massachusetts
  • 2Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
  • 3Associate Editor, JAMA Pediatrics
  • 4Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
  • 5Now with Takeda Pharmaceutical Company, Lexington, Massachusetts
  • 6Now with University of Washington School of Public Health, Seattle, Washington
JAMA Pediatr. 2021;175(8):807-816. doi:10.1001/jamapediatrics.2021.0747
Key Points

Question  Is enrollment in a high-deductible health plan (HDHP) associated with changes in asthma controller medication use and outcomes?

Findings  In this cohort study of 7275 children and 17 614 adults with HDHPs, among children with asthma in a setting where most HDHPs exempted medications from the deductible, children who switched to HDHPs had minimal or no significant reductions in 30-day fills and adherence for controller medications relative to those staying in traditional plans and no significant differences in asthma exacerbations. Findings among adults with asthma were similar.

Meaning  These findings suggest that enrollment in HDHPs may not be associated with changes in asthma medication use or exacerbations when medications are exempt from the deductible.


Importance  High-deductible health plans (HDHPs) are increasingly common and associated with decreased medication use in some adult populations. How children are affected is less certain.

Objective  To examine the association between HDHP enrollment and asthma controller medication use and exacerbations.

Design, Setting, and Participants  For this longitudinal cohort study with a difference-in-differences design, data were obtained from a large, national, commercial (and Medicare Advantage) administrative claims database between January 1, 2002, and December 31, 2014. Children aged 4 to 17 years and adults aged 18 to 64 years with persistent asthma who switched from traditional plans to HDHPs or remained in traditional plans (control group) by employer choice during a 24-month period were identified. A coarsened exact matching technique was used to balance the groups on characteristics including employer and enrollee propensity to have HDHPs. In most HDHPs, asthma medications were exempt from the deductible and subject to copayments. Statistical analyses were conducted from August 13, 2019, to January 19, 2021.

Exposure  Employer-mandated HDHP transition.

Main Outcomes and Measures  Thirty-day fill rates and adherence (based on proportion of days covered [PDC]) were measured for asthma controller medications (inhaled corticosteroid [ICS], leukotriene inhibitors, and ICS long-acting β-agonists [ICS-LABAs]). Asthma exacerbations were measured by rates of oral corticosteroid bursts and asthma-related emergency department visits among controller medication users.

Results  The HDHP group included 7275 children (mean [SD] age, 10.8 [3.3] years; 4402 boys [60.5%]; and 5172 non-Hispanic White children [71.1%]) and 17 614 adults (mean [SD] age, 41.1 [13.4] years; 10 464 women [59.4%]; and 12 548 non-Hispanic White adults [71.2%]). The matched control group included 45 549 children and 114 141 adults. Compared with controls, children switching to HDHPs experienced significant absolute decreases in annual 30-day fills only for ICS-LABA medications (absolute change, −0.04; 95% CI, −0.07 to −0.01). Adults switching to HDHPs did not have significant reductions in 30-day fills for any controllers. There were no statistically significant differences in PDC, oral steroid bursts, or asthma-related emergency department visits for children or adults. For the 9.9% of HDHP enrollees with health savings account–eligible HDHPs that subjected medications to the deductible, there was a significant absolute decrease in PDC for ICS-LABA compared with controls (−4.8%; 95% CI, −7.7% to −1.9%).

Conclusions and Relevance  This cohort study found that in a population where medications were exempt from the deductible for most enrollees, HDHP enrollment was associated with minimal or no reductions in controller medication use for children and adults and no change in asthma exacerbations. These findings suggest a potential benefit from exempting asthma medications from the deductible in HDHPs.

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