Will Medicaid Expansion Halt Smoking?

The Supreme Court’s decision to make the expansion of Medicaid optional for states has led to several natural experiments of the effect of providing Medicaid coverage. One such experiment explored how the expansion of Medicaid coverage impacted smoking cessation rates.

Medicaid has long had a higher portion of beneficiaries that smoke compared to the Medicare or the privately insured population. While there has long been evidence to support comprehensive tobacco cessation programs to support quitting, until the Affordable Care Act mandated that states provide these benefits few had taken up this opportunity. Whether many non-disabled, childless adults receive these benefits will vary based on whether states decided to expand Medicaid to low-income adults without children. Because of the Affordable Care Act, all states, regardless of whether they decided to expand Medicaid must offer smoking cessation as a mandatory benefit to pregnant women enrolled in Medicaid. Additionally all states that took up the Medicaid expansion have included it as a benefit.

The authors found that low-income residents living in Medicaid expansion states saw an increase in smoking cessation. The authors checked against residents over the age of 65 who would be eligible for Medicare. They found no evidence of a recent change in smoking cessation rates among people over 65. This implies that Medicaid expansion was the mechanism for reduced smoking rates.

Unfortunately, smoking cessation programs have not been implemented uniformly in all states. Some have implemented barriers to receiving smoking cessation services such as prior authorization or copayments. Such justification for placing limits on smoking cessation appears ill-advised.

Much attention has been paid to the growing opioid epidemic in America, and rightfully so. While thousands of Americans are dying prematurely because of opioid use, about fifteen times more die from smoking. Smoking cessation programs are proven effective with a $2 to $3 return on every dollar invested. Renewed attention to the health consequences of smoking can work toward reducing the high rate of annual deaths caused by smoking. A two percent reduction in smoking, as the authors find, has the potential to be a reduction in smoking related mortality for thousands of Americans.

Abstract

INTRODUCTION: Expanding Medicaid coverage to low-income adults may have increased smoking cessation through improved access to evidence-based treatments. Our study sought to determine if states’ decisions to expand Medicaid increased recent smoking cessation.

METHODS: Using pooled cross-sectional data from the Behavioral Risk Factor Surveillance Survey for the years 2011-2015, we examined the association between state Medicaid coverage and the probability of recent smoking cessation among low-income adults without dependent children who were current or former smokers (n=36,083). We used difference-in-differences estimation to examine the effects of Medicaid coverage on smoking cessation, comparing low-income adult smokers in states with Medicaid coverage to comparable adults in states without Medicaid coverage, with ages 18-64 years to those ages 65 years and above. Analyses were conducted for the full sample and stratified by sex.

RESULTS: Residence in a state with Medicaid coverage among low-income adult smokers ages 18-64 years was associated with an increase in recent smoking cessation of 2.1 percentage points (95% confidence interval, 0.25-3.9). In the comparison group of individuals ages 65 years and above, residence in a state with Medicaid coverage expansion was not associated with a change in recent smoking cessation (-0.1 percentage point, 95% confidence interval, -2.1 to 1.8). Similar increases in smoking cessation among those ages 18-64 years were estimated for females and males (1.9 and 2.2 percentage point, respectively).

CONCLUSION: Findings are consistent with the hypothesis that Medicaid coverage expansions may have increased smoking cessation among low-income adults without dependent children via greater access to preventive health care services, including evidence-based smoking cessation services.

PMID: 29068908 

Koma, JW, et al. Med Care. 2017; 55 (12): 1023-1029.