Asthma is the most common chronic condition among children in the U.S. and one of the leading reasons for pediatric emergency room (ER) visits. Schools play an important role in managing asthma among children since kids spend most of their time in school and school buildings may have environmental factors such as poor air quality and mold which can trigger asthma flare-ups. When asthma is uncontrolled, children are more likely to miss school and have lower academic performance than children without asthma. Existing data show that over 40% of children with asthma have uncontrolled asthma and that children with Medicaid coverage, who are Black or Hispanic, and who have lower household incomes are more likely to miss school due to asthma.
As kids go back to school this fall, we used HCCI's data on people with employer-sponsored insurance (ESI) and CMS data on Medicaid and CHIP to highlight the rise in children's visits to the ER for asthma that occurs during the school year. This increase is related to an increase in viral infections and allergen exposure in schools, as well as other seasonal factors. Evidence suggests that ER visits for asthma are generally preventable if asthma is managed well, yet children are twice as likely as adults to visit the ER for an asthma exacerbation. Reducing these visits by improving asthma management and ensuring access to a non-ER usual source of care—a Healthy People 2030 objective—has the potential to improve quality of care and reduce financial costs of treatment for families, given the high price of ER visits.
Following Declines in 2020, ER Visits for Asthma among Children Started to Rebound in 2021
We examined patterns in ER use among children with a primary diagnosis of asthma from 2018 to 2021. Use is measured as the number of ER visits per 100,000 enrollees. We compared levels and trends in visits between children with health insurance coverage through an employer (employer-sponsored insurance, or ESI) and Medicaid, as shown in Figure 1.
Figure 1. Asthma-Related ER Visits among Children with ESI and Medicaid, 2019-2021
We draw three main conclusions from this figure. First, rates of ER visits for asthma are higher among children with Medicaid than children with ESI in every month of our study period. In 2019 and early 2020, prior to the start of the COVID-19 pandemic, the average monthly rate of ER visits for asthma was 230-250% higher among Medicaid enrollees ages 0-17 than ESI enrollees in the same age group.
Second, we see clear seasonality in ER visit rates, consistent with existing evidence of asthma exacerbations in school. During the months that children are typically in school in 2019 (January-May and September-December) and into early 2020 (January-February), prior to the start of the pandemic, the average monthly rate of ER visits for asthma among children was just over 50 visits per 100,000 children enrolled in ESI and more than double that—123 visits per 100,000—among children enrolled in Medicaid/CHIP. Summer rates were almost 50% lower among all children.
Finally, consistent with broader trends in health care use and spending, we see a dramatic drop in asthma-related ER visits among kids in March and particularly April of 2020, coinciding with the declaration of COVID-19 as a national emergency and associated lockdowns and school closures. Between March and April of 2020, ER visits for asthma among children declined 82% (from 36 per 100,000 to 6 per 100,000) among children enrolled in ESI and 79% (from 89 per 100,000 to 19 per 100,000) among children in Medicaid.
Asthma-related ER visits started to increase in the second half of 2020, particularly in fall, coinciding with re-opening of some schools. These visits continued to rise over the course of 2021, potentially correlated with increased in-person instruction, and resulting in the return to some seasonality in visit rates with higher rates of asthma ER use in the fall of 2020 and 2021 compared to summer.
Figure 2. ER Visits for Asthma Remained Low Relative to 2019 through Mid-2021
Compared to 2019, children's ER visits for asthma were lower in 2020, and that trend continued through the first half of 2021. For example, in May of 2021, the asthma ER visit rate was 31% lower than the same month in 2019 among ESI enrollees and 43% lower than the same month in 2019 among Medicaid enrollees. By the end of 2021, ER visit rates for asthma were fairly similar to 2019 among children with ESI (50 visits per 100,000 in December 2021 compared to 56 visits per 100,000 in December 2019) but remained close to 30% lower among children with Medicaid (92 visits per 100,000 in December 2021 compared to 128 visits per 100,000 in December 2019). This lower rate among Medicaid enrollees may be due in part to a higher likelihood of and longer periods of school closures (thereby limiting exposure to viral illness and environmental factors in schools) in high-poverty areas.
As Kids Head Back to School, Trends Suggest Asthma ER Visits will Rise, Calling for Increased Monitoring and Management of Asthma Among Children
The onset of the COVID-19 pandemic sparked concern among health care providers that children with asthma might suffer from a greater number of severe asthma exacerbations given historical evidence that these instances are often triggered by other respiratory viruses. In 2020, however, our data show a large drop in ER visits among children. This could be, in part, the result of school closures that reduced exposure to respiratory viruses, including COVID-19. By the second half of 2021, ER visit rates for asthma among children remained lower but were beginning to return to pre-COVID trends, highlighting the importance of equipping schools to provide asthma education and management services.
Asthma is more prevalent among Black, Hispanic, and Native American populations, individuals with lower incomes, and populations with scarcer access to resources, particularly those with poor quality housing. Although not highlighted in this brief, our data also showed that people living in more socially vulnerable areas were 2-3 times more likely to have an ER visit with a primary diagnosis of asthma compared to people living in the least socially vulnerable areas. Ongoing work to understand where and among whom severe or persistent asthma has the largest impact, and to provide education and health resources for managing asthma, particularly among children, remain integral to improving health and educational outcomes and reducing disparities.
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