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A study of 31,219 U.S. commercial insurance plans found that lower-emission propellant-free inhalers for asthma and COPD had worse coverage and more utilization barriers than higher-emission metered-dose inhalers. Researchers called on payers to place at least one propellant-free option per drug class on preferred tiers.
Commercial insurance formularies are a major barrier to reducing greenhouse gas emissions from asthma and COPD inhalers, according to a study published in JAMA Network Open. Lower-emission dry powder and soft mist inhalers had less coverage and were less likely to be placed on preferred tiers without prior authorization or step therapy than metered-dose inhalers, which rely on hydrofluoroalkane propellants that warm the climate.
The analysis, led by Soko Setoguchi, MD, DrPH, of the Rutgers RWJBarnabas Center for Climate, Health, and Healthcare in New Brunswick, New Jersey, examined 31,219 commercial plans across all 50 states and Washington, D.C., using the MMIT Coverage Search in May 2026. It covered three medication classes — short-acting β2-agonists (SABAs), inhaled corticosteroids (ICS), and combination ICS-LABA inhalers — that together account for nearly all inhaler-related greenhouse gas emissions in the U.S.
For SABAs, 66.4% of plans covered only a metered-dose inhaler with no propellant-free option at all. While more than 99% of plans covered at least one ICS and ICS-LABA inhaler, propellant-free versions were covered by only 89.5% and 82.6% of plans, respectively.
The coverage gap was sharpest on formulary tier placement. Metered-dose inhalers had near-universal coverage on tier 1 or 2 without prior authorization or step therapy — 99.2% for SABAs, 93.8% for ICS, and 88.7% for ICS-LABAs. For propellant-free versions, those rates fell to 7.8% for SABAs, 61.8% for ICS, and 52.2% for ICS-LABA combinations.
Why Formulary Design Drives Inhaler Emissions
Inhaler-related emissions in the U.S. add up to the equivalent of roughly half a million gasoline-powered passenger vehicles driven for one year, according to the researchers’ prior work. Because many low-emission inhalers are already approved and on the U.S. market, the study’s authors argue the obstacle is not availability but insurance design that favors higher-emission products.
“A clinician might identify an environmentally friendly inhaler suitable for their patient, only to discover that the patient’s insurance does not cover it or requires extra steps to obtain it,” Setoguchi and co-author Ashwaghosha Parthasarathi, MBBS, said in an email. They noted that private insurance, despite generally offering better coverage than Medicare, imposed numerous barriers — a finding that echoed their earlier study of Medicare plans.
The VA Precedent and European Approach
The Veterans Health Administration offers one model for change. Its inhaler-related emissions dropped by 68% from 2008 to 2023, partly due to a cost-motivated 2021 formulary renegotiation that replaced budesonide-formoterol metered-dose inhalers with lower-emission fluticasone-salmeterol dry powder inhalers as the preferred ICS-LABA option.
However, a previous VA study found the switch came with a small increase in emergency and hospital care, which the researchers said points to the need for careful, evidence-based rollouts rather than blanket substitution. They highlighted European prescribing guidance as a more patient-centered model, promoting lower-emission inhalers through patient review and shared decision-making — an approach under which metered-dose inhalers now account for fewer than half of inhalers overall.
“Meaningful reductions in inhaler-related emissions in the U.S. will require lower formulary barriers for propellant-free options while preserving [metered-dose inhaler] access when clinically indicated.”
— Setoguchi and colleagues, JAMA Network Open
Study Limits and Unanswered Cost Questions
The analysis reflected plan-level formulary coverage, not individual patient enrollment, and did not measure actual out-of-pocket costs, coverage exceptions, prescribing or dispensing patterns, or whether switching devices is clinically appropriate for specific patients. The researchers also could not distinguish some generic products in the source data.
It is not yet clear whether payers will adopt the recommended formulary changes, or how quickly employers and benefits purchasers would pressure insurers to align coverage with sustainability goals.
Potential Payer and Policy Responses
The researchers called on U.S. payers to place at least one propellant-free option per class on preferred tiers, minimize utilization management such as prior authorization and step therapy for those options, and increase formulary transparency so employers can align benefits with access and sustainability goals. Whether insurers act on these recommendations, and whether clinical guidance similar to Europe’s shared decision-making model emerges in the U.S., remains to be seen.
Key Questions
Why are metered-dose inhalers considered bad for the environment?
They use hydrofluoroalkane propellants, greenhouse gases that warm the climate. U.S. inhaler-related emissions equal roughly half a million gasoline cars driven for a year, according to the researchers.
What are the lower-emission alternatives?
Dry powder inhalers and soft mist inhalers do not rely on hydrofluoroalkane propellants and are approved in the U.S., but the study found they receive worse insurance coverage.
Should patients switch away from metered-dose inhalers?
The researchers stressed preserving metered-dose inhaler access when clinically indicated and favoring shared decision-making with a clinician over blanket substitution. Patients should discuss options with their healthcare provider.
Has any health system successfully reduced inhaler emissions?
Yes — the Veterans Health Administration cut inhaler-related emissions by 68% between 2008 and 2023, though a linked study found a small increase in emergency and hospital care after switching some patients to dry powder inhalers.
Source: rss
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