Tobacco Cessation in Affordable Care Act Medicaid Expansion States Versus Non-expansion States

Abstract

Introduction Community health centers (CHCs) care for vulnerable patients who use tobacco at higher than national rates. States that expanded Medicaid eligibility under the Affordable Care Act (ACA) provided insurance coverage to tobacco users not previously Medicaid-eligible, thereby potentially increasing their odds of receiving cessation assistance. We examined if tobacco users in Medicaid expansion states had increased quit rates, cessation medications ordered, and greater health care utilization compared to patients in non-expansion states. Methods Using electronic health record (EHR) data from 219 CHCs in 10 states that expanded Medicaid as of January 1, 2014, we identified patients aged 19–64 with tobacco use status documented in the EHR within 6 months prior to ACA Medicaid expansion and ≥1 visit with tobacco use status assessed within 24 months post-expansion (January 1, 2014 to December 31, 2015). We propensity score matched these patients to tobacco users from 108 CHCs in six non-expansion states (n = 27 670 matched pairs; 55 340 patients). Using a retrospective observational cohort study design, we compared odds of having a quit status, cessation medication ordered, and ≥6 visits within the post-expansion period among patients in expansion versus non-expansion states. Results Patients in expansion states had increased adjusted odds of quitting (adjusted odds ratio [aOR] = 1.35, 95% confidence interval [CI]: 1.28–1.43), having a medication ordered (aOR = 1.53, 95% CI: 1.44–1.62), and having ≥6 follow-up visits (aOR = 1.34, 95% CI: 1.28–1.41) compared to patients from non-expansion states. Conclusions Increased access to insurance via the ACA Medicaid expansion likely led to increased quit rates within this vulnerable population. Implications CHCs care for vulnerable patients at higher risk of tobacco use than the general population. Medicaid expansion via the ACA provided insurance coverage to a large number of tobacco users not previously Medicaid-eligible. We found that expanded insurance coverage was associated with increased cessation assistance and higher odds of tobacco cessation. Continued provision of insurance coverage could lead to increased quit rates among high-risk populations, resulting in improvements in population health outcomes and reduced total health care costs.

Affordable Care Act Medicaid expansion and access to primary-care based smoking cessation assistance among cancer survivors: an observational cohort study

“…Despite these increased odds of smoking cessation medication orders among cancer survivors in expansion versus non-expansion states, we did not observe statistically significant differences in odds of quitting. These findings are in contrast to those of a previous study that found higher odds of quitting smoking among adult patients of CHCs in expansion states compared with those in non-expansion states; however, this prior study included the entire patient population and subanalyses for cancer survivors were not performed [ 20 ]. We postulate potential reasons for this finding.…”

Use of electronic health records to manage tobacco screening and treatment in rural primary care

“…Another proven approach to increasing the use of cessation assistance is to reduce patient cost barriers 60 . Research has shown that when health insurance offers comprehensive cessation coverage without cost‐sharing, patients are more likely to participate in treatment 10,61–63 and succeed in quitting 62,63 . Rural PCPs could work with local stakeholders and policy makers either to extend such comprehensive coverage to rural residents or to offer no‐cost cessation services to uninsured patients.…”

“…Another proven approach to increasing the use of cessation assistance is to reduce patient cost barriers. 60 Research has shown that when health insurance offers comprehensive cessation coverage without cost-sharing, patients are more likely to participate in treatment 10,[61][62][63] and succeed in quitting. 62,63 Rural PCPs could work with local stakeholders and policy makers either to extend such comprehensive coverage to rural residents or to offer no-cost cessation services to uninsured patients.…”

Effects of Medicaid coverage on receipt of tobacco dependence treatment among Medicaid beneficiaries with substance use disorder

“…[10][11][12] The late 2000s and early 2010s were a time of rapid expansion of coverage for tobacco dependence treatment (TDT) in state Medicaid programs; however, coverage continued to be variable, with most state plans excluding one or more evidence-based treatments (i.e., individual or group counseling, or FDA-approved medications). [13][14][15][16][17] For example, from 2009 to 2013, 15 states changed coverage for individual/group counseling; five states changed coverage for gum, patch, or lozenge; 14 states changed coverage for inhaler or spray, and six states changed coverage for bupropion or varenicline (see Appendix S1 for details). Medicaid recipients in states with comprehensive TDT coverage have higher quit rates 16,17 ; and enrollment expansions have increased rates of patient assistance and smoking cessation medication use.…”

“…Furthermore, studies evaluating the effects of TDT coverage expansion among the general population of Medicaid recipients have had limitations, including focusing on just a single state, 18 or focusing on patients already receiving tobaccorelated treatment at community health centers. 17 It remains unclear whether expanded TDT coverage, on a national scale, is associated with increased TDT use for adult Medicaid beneficiaries with SUD.…”