Pharmacoequity in Allergy-Immunology: Disparities in Access to Medications for Allergic Diseases and Proposed Solutions in the US and Globally

Abstract

Pharmacoequity is the principle that individuals should have access to high quality medications regardless of race and ethnicity, socioeconomic status, or availability of resources. In this paper, we summarize the access to therapeutics for allergic diseases in the US and other selected countries. We focus on domains of healthcare access (health insurance coverage, medication availability, and specialist access); and system-level factors, clinician- and patient-level factors, such as interpersonal racism, and cultural beliefs, and how they can affect timely access to appropriate therapy for allergic diseases. Finally, we propose how pharmacoequity in allergy-immunology can be achieved by highlighting solutions to the factors limiting access to medications for allergic diseases and identify potential future research directions.

Introduction:

Social determinants of health (SDoH) are the conditions in which individuals are born, grow, live, work, and mature, which significantly impact a person’s health and well-being(1). The United States (US) Department Of Health and Human Services’ Healthy People 2030 Framework identifies 5 SDoH components(2): economic stability, access to quality education, neighborhood and built environment, social community and context, and access to quality healthcare. Unequal distribution of the SDoH contribute to health disparities, which are differences in health outcomes or healthcare access that exist across populations, often perpetuated by structural racism(3). Moreover, health disparities are pervasive across many health conditions and outcomes, and occur globally, affecting low-, middle-, and high-income countries(4). Therefore, unsurprisingly, similar disparities are seen in allergic and immunologic conditions, as highlighted in the 2021 Work Group Report of the American Academy of Allergy, Asthma and Immunology’s (AAAAI) Committee for the Underserved (now the Diversity Equity Inclusion [DEI] Committee)(5). Black and Latinx populations are disproportionately burdened by allergic diseases, including a greater prevalence and severity of asthma and atopic dermatitis; and an under-diagnosis of allergic rhinitis(6–9). A better understanding of each SDoH component, such as access to quality healthcare, may allow us to combat health disparities and curtail the systematic perpetuation of these disparities. Access to the right therapy at the right time is a major component of the appropriate management of any chronic disease. Pharmacoequity is the principle that individuals should have access to high quality medications regardless of race and ethnicity, socioeconomic status, or availability of resources(10). In this review, we summarize the literature on healthcare access for allergic diseases in the US and other selected countries, focusing on access to medications for asthma, allergic rhinitis, nasal polyposis, eczema, and food allergy. We focus on domains of healthcare access presented in the Healthy People 2030 initiative: health insurance coverage, medication availability, and specialist access(2, 11). In addition to these system-level factors, we evaluate clinician- and patient-level factors, such as interpersonal racism, implicit bias, and cultural beliefs , which can affect timely access to appropriate therapy for allergic diseases (Figure 1). Finally, we propose solutions to the factors limiting access to medications for allergic diseases and identify potential future research directions.

Figure 1:

Domains through which pharmacoequity is operationalized in allergy-immunology (Created with BioRender.com).

Insurance and availability of medications for allergic diseases:

Prescription costs and insurance payment models are arguably the most important factors determining access to medications for allergic diseases both from the healthcare system and the patient perspective. In the US, about 60% of individuals are covered under an employer-based private insurance policy and about one-third are insured under the Federal Government (FG)-funded Medicare policy for adults aged ≥65 years, people with long-term disabilities, and patients with end-stage renal disease.(12) The FG also co-funds the individual State-run Medicaid programs for low-income individuals and under which the Children’s Health Insurance Program (CHIP) falls.

Each insurer is given the flexibility to determine its benefit terms and patient cost-sharing package leading to payer flexibility but contributing to the complexity of payment models.(12, 13) Medicare is organized in multiple parts to include Part A which pays for inpatient care, Part B which includes payments for clinic visits, durable medical equipment, and injectables or infusions administered in the hospitals. Part C, also known as Medicare Advantage, allows Medicare-eligible individuals to enroll in a private managed care organization, and Part D, under which most prescription drugs and allergy medications fall, is optional. For patients on private plans, prescription drug coverage can be integrated with medical health insurance (“carve-in”) or received outside medical insurance (“carve-out”). In patients with chronic diseases, carve-in insurance may be associated with better coverage and health outcomes.(14) However, these payment models are complicated, and services covered can differ significantly between patients with seemingly similar plans, with patient out-of-pocket costs varying widely depending on the plan type (High Deductible Health Plans [HDHP] vs. Managed Care Plans [MCP]), the drug formulation and delivery-method (injectable vs. infusion, home vs. in-office) and the chronicity or severity of the disease.(13)

Prior studies have shown that children and adults with chronic diseases like asthma are more likely to be covered under a government-funded insurance plan.(15) However, benefit packages can also vary widely in what allergy and asthma medications are covered even within Medicaid due to the large number of managed care organizations that contract with Medicaid.(15) These complexities create challenges for providers in anticipating potential cost barriers to medication access for their patients,(16) and navigating these complexities can be especially tough for people with low literacy, low income, or with limited access to specialists or providers.(17, 18)

In 2010, the Affordable Care Act (ACA) was enacted with a goal of reducing cost barriers to healthcare. Though the ACA has led to substantial reductions in uninsured patients,(12, 19) and more recently, Medicaid Expansion (ME) extended public insurance coverage to citizens and permanent residents below 138% of the federal poverty level,(17) many studies have shown that many adolescents and adults, including those with asthma, remain inadequately insured or underinsured.(19, 20) A 2022 study found that over one-fifth of insured patients with asthma reported cost barriers to accessing controller therapy.(19)

Improving or extending coverage, for instance, via the dependent coverage extension (DCE) in which young adults can continue to receive health insurance coverage under their parent’s plan has however led to reductions in cost-related challenges to accessing appropriate asthma care, suggesting that indeed alleviating cost barriers can improve access to allergy and asthma medications.(21, 22) High out-of-pocket costs for prescription medications have been associated with lower adherence to asthma control medications,(20, 23–25) and higher utilization of emergency room visits for asthma based care.(26, 27) Furthermore, individuals belonging to historically minoritized groups are less likely to have their asthma care ‘stepped-up’ to receiving asthma controller medications than White people.(28) In one study, historically minoritized people had 45% lower odds of receiving inhaled corticosteroids for their asthma compared to White people.(29) Similarly, in a recent study of children with atopic dermatitis, Medicaid-insured children were less likely to be prescribed high-potency topical corticosteroids and calcineurin inhibitors in comparison to their privately insured counterparts.(30)

Alleviating these disparities however requires a multi-pronged approach with no easy fixes. For instance, telemedicine, especially since the onset of the COVID-19 pandemic, has been suggested as a strategy to improve specialist access and access to asthma-based care.(31–33) However, many patients with asthma who are publicly insured or of low socioeconomic status (SES) may not have reliable internet access or enough technology knowledge to leverage these services.(34) Thus, limiting the value of telemedicine in this population.

Patent protections, approval of expensive inhaler delivery devices,(35) unavailability of over the counter (OTC) allergy medications,(36) and the approval of many monoclonal antibodies estimated to cost $30,000-$40,000 per patient per annum(37-39) for the treatment of asthma, have contributed to high costs associated with asthma treatment(40). To this end, payers have instituted prior authorizations and policies geared towards restricting access and reducing costs for payers.(15, 16, 41, 42) However, these strict prior authorization processes may limit access unwittingly to beneficial therapies, may take weeks for approval, and can be disconcerting to both patients and providers.(16) There is ample evidence that higher patient cost-sharing is associated with lower healthcare utilization.(16, 17, 35) Access to allergy medications may also improve by making more of them available OTC, but this may shift the responsibility of determining the right therapy from providers to patients, and might not be the appropriate course of action for many therapies with significant adverse effects.(36) Respiratory biologics, due to their cost, are one of the main groups of allergy or asthma medications requiring prior authorization. Many studies have shown that publicly insured patients, despite bearing a disproportionate burden of uncontrolled asthma, are less likely to be prescribed these biologics for the treatment of asthma.(18, 43, 44) Even when prescribed, patient cost-sharing may impede use of these therapies. For example, a 2019 mixed methods study evaluated the use of respiratory biologics across six specialty clinics in the US in a cohort of patients with asthma where 77% identified as White and half of the patients had a college degree or higher. Of the 8 potential factors influencing patients when selecting a biologic, ‘out-of-pocket costs’ was overwhelmingly the most important factor, with 45% of patients ranking it as most important, with ‘mode of administration’ and ‘time to onset of efficacy’ ranked as the most important factors 28% and 15% of time, respectively.(45)

Out-of-pocket costs are also a hindrance to asthma care in terms of accessible controller medication. In an observational study by Sinaiko et al using census, claims, and enrollment data in the US, it was seen that the out-of-pocket cost for the important controller medication of ICS-LABA increased and remained high during the study period. They also found that low income patients, spent more of their out-of-pocket costs on high acuity care, and less on controller medications; and that they bare a greater cost burden of asthma care.(46) Out-of-pocket costs for asthma medications also impact care-seeking behaviors. A survey study performed by Fung et al, found that California families within a managed care health system, at or below 250% of the federal poverty guidelines, had higher cost sharing delayed seeking care for their children. In comparison, those within the same federal poverty guideline but with lower cost sharing were less likely to delay an office visit or emergency room visit, odds ratio [OR], 0.07 [95% CI, 0.01–0.39]) and 0.05 [0.01–0.25], respectively.(47)

Insurance and availability of medications for allergic diseases in countries outside of the United States:

The United Nations promotes universal health insurance in all countries as a mechanism to promote health and wellbeing(48). Indeed, universal health insurance is available in many countries worldwide, although with varied funding mechanisms, methods of implementation, and extent of coverage of medications and access to specialist care(49). For example, Chile has universal health insurance that guarantees access to treatments for many high impact conditions, but atopic dermatitis is not one of them(50). A recent Lancet commission identified widespread fragmentation across countries in their efforts to promote universal healthcare, health security, and health promotion(51).

Disparities in access to medicines for allergic diseases have implications globally. Low- and middle-income countries (LMIC) account for most global asthma-related deaths (96%) and disability-adjusted life-years (84%)(52), and their populations are more likely than those in high income countries (HIC) to have poor asthma control(53). To address this disparity, the World Health Organization recommends countries to have national essential medicines lists (EML) to increase access to efficacious drugs (e.g., inhaled corticosteroids) through reimbursement schemes, donations, and local production(54). However, despite LMICs being more likely than HICs to have EMLs(55), LMICs very often have poor availability of efficacious asthma medicines listed in their EMLs(56). For example, in rural parts of India, non-adherence to asthma controller therapy is approximately 50%, often attributed to unaffordable out-of-pocket costs(57). Although the burden of disease from atopic dermatitis seems to be greatest in HIC(58), disparities in access to atopic dermatitis medicines (e.g., topical corticosteroids) have been noted, for example, across Latin American countries(50), in regions with disproportionate numbers of displaced populations(59), and elsewhere. Epinephrine auto-injectors constitute first-line treatments for severe allergic reactions from food allergies but are very expensive and incur nearly $300 million USD per year in the US alone. The availability of epinephrine autoinjectors is limited worldwide(60). There are limited data on the availability of efficacious medicines for rhinosinusitis and nasal polyposis across countries.

Referrals and access to specialists:

The uninsured or under-insured get limited referrals and access to specialist care for allergic diseases.(30) Specialists prescribe the overwhelming majority of allergen immunotherapy and the monoclonal antibodies approved for the treatment of asthma, atopic dermatitis, and chronic rhinosinusitis with nasal polyposis. Thus, limited access to specialists means limited access to these therapies(44). Limited specialist referrals can reduce healthcare quality, since specialists may also be more aware of recent updates in evidence-based guidelines and of the need to escalate therapy as appropriate.(16, 61) For example, patients with private insurance were twice as likely to be prescribed respiratory biologics compared to their publicly-insured counterparts.(43, 44)

Primary care clinicians’ lack of knowledge about these therapies or their indication also frequently reduces referrals to specialists. For example, an Irish study surveyed pediatricians and found that half were unaware of the indications for allergen immunotherapy, and forty percent identified accessibility as a barrier consisting of not knowing where to refer or lacking local services.(62) In a prospective study of 852 patients with chronic rhinosinusitis followed over 5 years at a US academic center, Black and Latinx patients were 13% and 29% less likely to be seen by allergists-immunologists compared to White patients, respectively.(63) In a descriptive study of 220 urban historically minoritized children with asthma, 83% of the children had not seen an asthma specialist.(64) Patients with eczema with public health insurance also have limited access to specialists for the management of their eczema. In a retrospective cohort study using insurance claims data, only 3% of 268,580 children with eczema had seen a dermatologist and 3% an allergist/immunologist in the Medicaid cohort, compared to 20% and 10% respectively for 338,678 children in the commercial health insurance cohort.(30) Using data from the 2010 and 2012 National Health Interview Survey, Silverberg et al. found that adults with eczema, relative to those without, had 1.9 times greater odds of being unable to get an appointment “soon enough” and 1.3 times greater odds of “having to wait too long to see a physician”.(65) Similar issues with limitations in access to specialist care are also seen in food allergy. In a retrospective chart review of 313 children with food allergy, Taylor-Black and Wang determined that only 47% had been seen by an allergist-immunologist(66). This limited number of referrals to allergists-immunologists have important repercussions in their management, since patients seen by allergists-immunologists were 38% more likely to have epinephrine auto-injectors. Children seen by allergists-immunologists were the only ones with documented action plans for food allergy. In another retrospective chart review of two tertiary urban centers with 817 children, Black and Latinx children had statistically significantly shorter durations of follow-up for food allergy with an allergist-immunologist consisting of 2.32 years and 2.22 years, respectively, compared to Whites with 3.20 years (p<0.001 and p=0.003, respectively).(67)

Referrals and access to specialists in countries outside of the United States:

In countries outside the US, care for allergic diseases is typically provided by primary care clinicians and not specialists (i.e., allergists-immunologists, pulmonologists, otorhinolaryngologists, or dermatologists), especially in countries and communities with limited resources(68)(69, 70). A limited numbers of specialists is a common barrier to adequate care globally for asthma (71-75), allergic rhinitis(76, 77), atopic dermatitis(78, 79), and food allergies(80). For many of these regions worldwide, the lack of specialist care is compounded by an unclear assessment of the prevalence of these allergic diseases such that resources are not earmarked appropriately.

Clinician-level factors that underlie structural racism:

The 2003 “Unequal Treatment” Report from the Institute of Medicine was the first of its kind to identify systemic racism as the cause of racial disparities(81). This report highlighted that even after adjusting for healthcare access and other socioeconomic factors, being of Black, Latinx, or Indigenous race predicted worse health outcomes. Additional research since then has further clarified that systematic racism faced by Black, Latinx, and Indigenous people is an important cause of disparate outcomes rather than race in itself.(3, 82-84) This report emphasized three mechanisms on the clinician level or the healthcare process-level by which racial disparities were mediated: (1) prejudices held by the clinician against historically minoritized groups; (2) stereotypes (positive or negative beliefs) about the behavior or health of historically minoritized patients (e.g., that Blacks and Latinx individuals are more likely to be nonadherent to their asthma controller therapy); and (3) greater clinical uncertainty when interacting with minoritized patients due to a lack of clinical research conducted in these populations(81). These prejudices and stereotypes reflect our historical, cultural, and social norms in the US, and can negatively impact clinical decision-making, communication, and the patient-clinician therapeutic alliance.(85, 86) Nonetheless, similar factors underlying structural racism can also be found in countries other than the United States(87-91). Previous literature demonstrates that most clinicians have anti-Black/pro-White bias. Although understudied in allergic diseases, we can extrapolate that allergist-immunologists are similarly not immune to these biases, ultimately affecting treatment access for historically minoritized patients.

Patient-level factors that underlie structural racism:

The impact of culture and language on access to medications for asthma and allergies is complex especially in individuals belonging to historically minoritized groups in the US(92) and elsewhere(93). In a survey study performed in the UK utilizing the Millennium Birth Cohort, households that required a translator reported half the amount of asthma and wheeze than those who were able to perform the interview in English(94). Certain cultural practices or acculturation can promote access while others can limit it(95, 96). Culture can influence symptom perception, the understanding of allergic diseases, and their management.(97) Several studies have demonstrated that historically minoritized groups with lower health literacy, amidst preexisting biases in the healthcare system, are more likely to face greater challenges in understanding their disease and in leveraging or seeking appropriate health services.(98, 99) This can manifest as a misunderstanding of allergic disease, including that asthma is a purely acute or contagious disease.(100) For example, in multicultural countries such as Malaysia, communication with patients often requires incorporating concepts of disease based on “hot” and “cold” imbalances(101). In certain communities, even when preventive and/or controller medications are prescribed, they may be underused due to a belief that the risks of treatment outweigh the benefits. For example, Black and Mexican parents have reported concerns around their children becoming addicted to asthma medications,(102) while some Muslim patients may be reluctant to accept inhaled treatments containing alcohol.(103, 104) Instead, among several historically minoritized groups, such as the Latinx and Vietnamese cultures, traditional herbal medicine may be viewed as more holistic and thus preferred over pharmaceutical medications and inhalers.(42, 98, 105) The values of these folk remedies, such as traditional foods, herbs, healing bracelets, and even antibiotics may be considered more valuable to asthma treatment with patients expending resources to get these rather than seeking access to traditional medications with evidence-based demonstrated efficacy.(106)

Future research:

SDoH’s correlation with race and ethnicity is well-documented in the United States but is evident in other countries(107). Although the unequal distribution of the SdoH negatively impacts everyone, it is important to understand which specific groups face a disproportionate burden of disease. Recruitment of historically minoritized groups into clinical research that reflects or exceeds their proportional representation in society needs to be emphasized. One example is the lack of racial diversity in oral immunotherapy (OIT) trials where White subjects are often overrepresented. This lack of diversity in the trial setting will likely affect subsequent uptake and dissemination in the community, as OIT guidelines were not evaluated in diverse settings. In a paper by Smith et al in 2021, the authors showed that there were only six Black participants in total among 231 participants (sample sizes ranged from 10-120 participants) enrolled across five seminal peanut-OIT clinical trials between 2017-2019.(108) The authors stress this lack of racial diversity in the peanut OIT trials will likely worsen food allergy treatment disparities as feasibility was not thoroughly evaluated which is exemplified by the time-burden of OIT initiation and build-up appointments.

Adequate recruitment of historically minoritized groups in clinical research not only is necessary to disentangle the relationship between race and ethnicity, SDoH, and health outcomes, but also to identify the causal pathways unique and relevant to specific historically minoritized and other groups. For example, a recent study conducted exclusively in Black and Latinx adults with moderate-severe asthma found that lower socioeconomic status is a predictor for worse asthma morbidity within these racial and ethnic groups, and identified that stress is an important mediator of this association(109). Many studies using omics strategies have also focused on the identification of causal pathways underlying the risk for allergic diseases. These studies, such as a recent study of patient endotypes based on transcriptomic signatures of epithelial tissues, focused on the development of biologics through the identification of targets and on the clinical implications for personalized medicine.(110) However, the use of these omics strategies may have broader clinical implications beyond personalized medicine as better understanding causal pathways in historically minoritized groups might improve our understanding of disease risk and severity and may help combat health disparities. The prevalence and impact of structural racism on outcomes of allergic diseases also requires further research so that effective solutions can be identified and implemented(111).

Discussion and Proposed Solutions:

Limited access to quality healthcare, often perpetuated by structural racism, contributes to health disparities in access to medications for allergic diseases. Complicated health insurance payment models make it difficult for both clinicians and patients to know how much they will pay out-of-pocket for their medication for allergic diseases even across seemingly similar plans. Even though healthcare insurance reform has expanded coverage in the United States, such as that introduced with the ACA and ME, those who remain under- or uninsured face barriers to accessing controller therapy for asthma. In general, high out-of-pocket costs contribute to medication non-adherence, which is a risk factor for greater morbidity from allergic diseases. Pharmacoequity could be further accomplished by implementing universal, low cost prescription drug coverage; increasing access to physical pharmacies; decreasing differential prescribing (or inconsistent prescribing) at the clinician level; and increasing recruitment of historically minoritized groups in medical research(10). Additionally, although technologies such as telemedicine could facilitate access to specialists, many insurance plans are beginning to discontinue reimbursements for telehealth visits(112) and individuals with low literacy, low technology skills, or poor broadband access will be less likely to benefit from these digital innovations.

Although asthma is viewed as a costly disease, its exact economic burden varies country to country. The European Community Respiratory Health Survey II (1999-2002) found that the mean total cost per patient ranged from €509 (controlled asthma) to €2,281 (uncontrolled disease); and €19.3 billion expected total costs for the entire European population (15y-65y)(113). Healthcare costs related to asthma are expected to exceed $960 billion over the next 20 years in the US alone(40). A substantial proportion of these expenditures could be prevented through improved adherence to controller therapy, which in turn could be optimized by facilitating access to affordable controller therapy and specialty care. This is true especially in LMICs which drive most of the global burden of disease from asthma. Since non-adherence to inhaled corticosteroid-based controller therapy is widely prevalent, the relatively recent uptake of as-needed inhaled corticosteroid strategies into international and American asthma guidelines could help reduce asthma related morbidity and costs as long as these combination inhalers are made affordable and accessible to the public(114). Currently, even though single maintenance and reliever therapies (SMART) with the use of ICS/formoterol in a single inhaler as both controller and reliever therapy has demonstrated efficacy and robust reductions in asthma exacerbations for decades, few patients can use SMART therapy in the US due to barriers to access from lack of coverage by health insurance plans for this indication(115) (Table 1). Further, most patients with asthma are managed by primary care clinicians globally(116)(69, 70).

Table 1.

Strategies to Improve Access by Domain in the US

Access Domain	Issue	Strategy
Insurance	Coverage Gap	Encourage Medicaid Expansion
Insurance	Specialist access	Promote legislation supporting telemedicine
Insurance	Prior-authorization	Encourage payers to streamline prior-authorization process
Cost	Adherence and cost-effectiveness	Ensuring insurance coverage is consistent with the most up-to-date disease specific guidelines, e.g. SMART therapy
Cost	Decrease out-of-pocket medication costs	Promote generics and limit patent laws on brand name drugs
Referrals	Lack of knowledge of indications for referral	Primary care physician education
Patient- and Clinician-level	Language	Having on-site interpreters vs remote interpreter services Having educational hand-outs in common languages
Patient-level	Cultural beliefs	Community health fairs highlighting A&I conditions Increasing recruitment of historically minoritized groups in medical research
Clinician-level	Implicit bias	Incorporating implicit bias training in medical school, Graduate medical education, and continuing education curricula Increasing historically minoritized group recruitment into the physician workforce and into investigator positions

Facilitating referrals to respiratory disease specialists who are more likely to be familiar with the greater efficacy of strategies such as the as-needed use of inhaled corticosteroids could lead to improved asthma morbidity at a systems level(75). This could include educating primary care providers on indications for referral to allergy and immunology physicians. In the US, policymakers could facilitate referrals by simplifying the referral process and ensuring the coverage and affordability of visits to specialists for patients. To reduce morbidity from allergic diseases, policies should “meet patients where they are” and adapt to the needs and situations in which they seek care. For example, many patients use the emergency room as the main resource for seeking asthma care, without otherwise seeing a primary care physician or a respiratory disease specialist. This pattern creates unnecessary costs to the system which perhaps could be avoided by facilitating access to specialists and thus a better understanding of asthma management. Further, biologics for asthma are very effective at reducing asthma exacerbations, yet >90% of asthma biologics are prescribed by respiratory specialists(44), and therefore inaccessible to population that relies on the ER for asthma care. Strategies that streamline connecting these patients, particularly those with severe disease, to specialists who can prescribe biologics could result in reductions in asthma morbidity and net cost savings to the system from the reduction in ER visits and hospitalizations, although this point needs to be examined through randomized controlled trials. In Canada, despite universal healthcare there is significant heterogeneity in patient access to care. Godbout et al, proposed a Canadian severe asthma program where consensus recommendations included: utilizing pharmacists to identify patients with severe asthma; defined unified approach to when to refer patients with asthma to specialists; and initiation of a biologic within 2 to 4 weeks of approval(70).

Understanding the impact of structural racism on allergic disease outcomes is imperative, as it will further help us identify and correct clinician- and patient-level factors that perpetuate structural racism. A potentially modifiable factor includes implementing implicit bias training in healthcare education including medical school, graduate medical education, and in continuing education curricula. In a study by Gatewood et al, educational sessions incorporating the Implicit Association Test in 4 nursing schools led to an increased awareness of implicit bias in 83% of students and 90% thought this would help them care for patients in the future(117). Language is also an area that can be optimized. Video and phone interpreter services facilitate the use of interpreters in healthcare settings. In a descriptive study by Lundin et al. within two emergency rooms in two culturally diverse cities in Sweden, they found that those needing interpreter services had longer wait times, less empathic interactions with healthcare providers, and less time to ask questions compared to those who spoke the native language (118). Potentially increasing the diversity of the physician workforce and cultural competency/humility training could mitigate these findings.

Conclusions:

Throughout the past several decades scientific breakthroughs have yielded novel therapeutic options for many allergic diseases. However, persisting morbidity and mortality from these diseases is largely attributable to incomplete access to quality healthcare and medications. Studies on the impact of SDoH on morbidity from allergic diseases would help identify the patient groups that disproportionately suffer from these diseases. Policy changes based on these studies could facilitate access to adequate healthcare insurance, medications, and specialty care.

Abbreviations used

SDoH

Social determinants of health

AAAAI

American Academy of Allergy, Asthma, and Immunology

AR

Allergic rhinitis

CRSwNP

Chronic rhinosinusitis with nasal polyposis

FG

Federal government

CHIP

Children’s Health Insurance Program

HDHP

High deductible health plans

MCP

Managed care plans

ACA

Affordable Care Act

ME

Medicaid Expansion

DCE

Dependent coverage extension

COVID-19

Coronavirus Disease 2019

SES

Socioeconomic status

OTC

Over-the-counter

LMIC

Low- and middle-income countries

HIC

High income countries

EML

Essential medicines list

OIT

Oral immunotherapy

SMART

Single maintenance and reliever therapy