Asthma treatment has made enormous strides in recent years. With improved care and better medicines, most people can control their condition and live full, normal lives.

But not everyone is benefiting. For the millions of people in the U.S. with low incomes and little or no insurance, the high costs can make asthma treatment difficult.

"The treatment costs are an enormous problem for many people with asthma," says Norman Edelman, MD, a pulmonologist and Chief Medical Officer for the American Lung Association. "And the problem is getting worse instead of better."

A staggering 43% of all people with asthma said that, in the past year, they did not have the money to pay for their treatment, according to the 2005 Health Costs Survey sponsored by the Kaiser Family Foundation, the Harvard School of Public Health, and USA Today.

"There are no easy answers and no perfect solutions to this problem," says allergist Jonathan A. Bernstein, MD, associate professor of clinical medicine at the University of Cincinnati College of Medicine. But there are ways for savvy patients to save on their asthma treatment.

The High Cost of Asthma

Asthma is a costly disease. People with moderate to severe asthma often need at least three different drugs , says Mo Mayrides, director of public policy at the Asthma & Allergy Foundation of America.

A 2003 study published in the Journal of Allergy and Clinical Immunology estimated the annual costs for asthma treatment at over $4,900 per person. These include both direct costs -- such as medicine and visits to the doctor or hospital -- and indirect costs, such as time off from work. Medicines make up about half of the expense.

The uninsured are at the greatest risk. More than one in six people with asthma don't have insurance, according to a 2005 study prepared by the Urban Institute and the University of Maryland, Baltimore County. That adds up to about 2 million Americans.

As costs rise, many people with limited resources try to stretch their medication. One 2004 study published in The Journal of the American Medical Association found that when co-pays doubled, people with asthma reduced the use of their drugs by 32%. They stopped taking their medicine every day. They began to use it only for emergencies.

The 2005 Health Costs Survey bears this out. The researchers found that 44% of all people with asthma tried to save cash by not taking their medicine or skipping doctor's visits.

"I see people with asthma rationing their medicines all the time," says Edelman.

But while conserving makes sense in other parts of your life -- like lowering your thermostat to save on heating bills -- it doesn't work with asthma treatment. For people with moderate to severe asthma, daily medications are the bedrock of treatment. If you only treat flare-ups, your asthma is likely to get worse. A passive approach, in which you wait for things to worsen, will lead to greater long-term costs.

"If you let your asthma get bad and have an attack, that's a really bad thing," says Edelman. "You'll have to pay for the ER bills and make up for the time you miss from work."

Among uninsured people with asthma, 52% say that they are not getting the medical care they need. And people with low incomes report spending up to 10% of their total annual earnings on asthma care.

Perhaps surprisingly, the very poor are not the worst off, since they may qualify for public assistance.

"Medicaid is the best insurer now," Edelman tells WebMD. "So the poorest people with asthma are often in the best shape."

People who have limited incomes but don't qualify for Medicaid face a tougher situation. Many earn too much to get public assistance but work for employers who offer little or no insurance. Some retired people with limited incomes don't qualify for Medicaid because they have too much money in assets, like a house, says Edelman.

Younger people who have just graduated from college are also vulnerable. They lose their insurance they had from their school or parents, but don't yet have a job that offers benefits.

However, the uninsured aren't the only ones in trouble. People with insurance are feeling pinched, too.

"Even people who have insurance are having trouble affording the higher and higher co-pays for medicines," says Edelman.

Safer Ways to Lower Drug Costs

Medications are the biggest expense for people with asthma, says Bernstein. But there are ways of lowering your cost.

• Ask your health care provider and your pharmacist about taking generic medicines instead of brand name drugs. Although there are a limited number of generic asthma medicines available, they can be substantially cheaper, says Mayrides.
• If you have health insurance, look into mail order prescription plans, recommends Bernstein. "You can sometimes save quite a bit of money with mail order," Bernstein tells WebMD. "For instance, you might get three prescriptions for the price of two."
• Edelman says that in some cases, using older and out-of-fashion medicines may be a good idea. "When I have a patient who is in especially difficult financial circumstances, I rely on drugs that many physicians no longer use," Edelman says. He says that while dyphylline may have greater side effects than newer drugs, it works well and is inexpensive. In some cases, he also uses the oral corticosteroid prednisone. "It's a very good asthma drug and it's very cheap," he says, "However, the side effects are substantial if you use it for a long time."
• You could also ask your health care providers for free samples of prescription drugs. While it is not a long-term solution, it could help you make it through a particularly difficult stretch.

Asthma Drug Assistance Programs

People with low incomes can get help with medical bills in various ways. Thirty-two state governments have programs that help pay for drugs for people who don't qualify for Medicaid. However, many are only open to seniors.

Another option is to get assistance directly from pharmaceutical companies. Many of them have programs that give free medicine to eligible people.

The requirements vary from program to program. For instance, GlaxoSmithKline's "Bridges to Access" program sets the income cap at $25,000 for single people or 250% of the federal poverty limit for families. The AstraZeneca Foundation's Patient Assistance Program gives free medicines to eligible single people who make $18,000 or less or couples who make $24,000 or less.

The best way to find out about these programs is to get in touch with the Partnership for Prescription Assistance (www.pparx.org or 1-888-477-2669.) This organization directs people to more than 475 public and private assistance programs, including more than 150 programs offered by drug companies.

Once catch is that pharmaceutical companies only give you access to their own products.

"If you need more than one drug from different manufacturers, you'll need to join multiple drug assistance programs," says Bernstein.

Mayrides also recommends Rx Outreach (www.rxoutreach.com or 1-800-769-3880), which offers a similar program for generic medicines.

Joining the programs can be complicated. Some require that a doctor or nurse apply on your behalf. The company may also send your prescriptions to your doctor's office and not your home. Although the drugs themselves are usually free, you may have to pay a fee for shipping or a small co-pay.

The programs may also be time limited. "Joining these programs won't give you a lifetime supply of free medicine," Mayrides tells WebMD.

Everyone with asthma should also be using environmental control to reduce exposure to allergens. But it's especially important if you really can't afford to pay for medication, says Bernstein.

Some ways of reducing your exposure are fairly cheap. Quitting smoking will help you feel better and save you money. Wrapping your mattress and box spring in vinyl to keep out dust mites can cost as little as $20, says Bernstein.

For people who are allergic to cockroaches, the best precaution is to keep your home scrupulously clean, Edelman tells WebMD. While exterminators or roach bait may kill the roaches, their bodies may keep giving off the antigen that aggravates your asthma.

Other measures may cost more up front but be worth it in the long term.

For instance, if your home is damp, see if you can get a dehumidifier. Although they are pricey, many people with asthma do better if the humidity is below 50%.

"I know they're expensive, but I encourage people to save up for an air conditioner," says Edelman. "It can make a huge difference." Air conditioners can filter out pollen and other allergens.

But experts acknowledge that environmental control is often easier in theory than it is in practice.

"Improving the air quality in your home does require some money," says Bernstein. "Although you can do it wisely and cost effectively, if you have very few resources, it's still going to be tricky."

Bernstein also points out that, if you live in a city or industrialized area, you may be at the mercy of irritants and allergens you can't control.

"Environmental control can be a pretty big burden," says Mayrides. "Although it's cheaper than medication, taking medicine is often a lot easier."

Working With Your Doctor

Experts stress that you should be honest and direct with your doctor about your financial situation.

"Patients need to be up front," says Edelman. "I know it can be embarrassing. But if you can't afford a medicine, you need to look your doctor in the eye and say so. Then your doctor may be able to come up with a new solution."

You need to advocate for yourself. "People need to be proactive," says Bernstein. "They need to be asking their doctors and pharmacists about any ways to lower the cost of their treatment."

Edelman says that doctors need to be more sensitive to a patient's finances.

"As doctors, we should be doing a better job of helping people with limited resources," says Bernstein. "We need to be more creative. We need to help them find ways for them to get the treatment they need."

Whatever you do, don't ignore your condition. If you haven't had an asthma attack recently, you might be less careful about your treatment than you should be, says Edelman. It is easy to let your treatment slide, especially if your finances are tight.

"Ignoring your asthma isn't good for you and it doesn't make sense financially," says Edelman. An asthma attack -- whether yours or a family member's -- could force you to take time off from work. Losing that income can be a devastating blow to your finances.

"I always tell people to make their asthma care a financial priority," he tells WebMD. "It will save you money in the long-run."