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State Medicaid Expansion Tobacco Cessation Coverage and Number of Adult Smokers Enrolled in Expansion Coverage — United States, 2016





Anne DiGiulio1; Meredith Haddix1; Zach Jump, MA1; Stephen Babb, MPH2; Anna Schecter, MPH2; Kisha-Ann S. Williams, MPH2; Kat Asman, MSPH2; Brian S. Armour, PhD2 (View author affiliations)

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Summary

What is already known about this topic?

Medicaid enrollees smoke cigarettes at a higher rate than do privately insured U.S. residents. States that expand Medicaid eligibility are able to extend coverage to large numbers of adult smokers who are not eligible for traditional Medicaid cessation coverage, thereby substantially increasing the potential impact of Medicaid cessation coverage.

What is added by this report?

By expanding Medicaid eligibility under the Affordable Care Act, 32 states have extended Medicaid cessation coverage to about 2.3 million adult smokers who were not previously eligible for Medicaid. All 32 of these states covered some cessation treatments for all Medicaid expansion enrollees. Nine states covered all nine cessation treatments considered in this study for all Medicaid expansion enrollees, and 19 states covered all seven FDA-approved cessation medications for all enrollees. All 32 states imposed one or more barriers to accessing at least one cessation treatment for at least some enrollees.

What are the implications for public health practices?

States that have expanded Medicaid can take further steps to help smokers quit by covering proven cessation treatments more fully, removing barriers to accessing covered treatments, making Medicaid enrollees and their health care providers aware of these treatments, and monitoring use of these treatments.


In 2015, 27.8% of adult Medicaid enrollees were current cigarette smokers, compared with 11.1% of adults with private health insurance, placing Medicaid enrollees at increased risk for smoking-related disease and death (1). In addition, smoking-related diseases are a major contributor to Medicaid costs, accounting for about 15% (>$39 billion) of annual Medicaid spending during 2006–2010 (2). Individual, group, and telephone counseling and seven Food and Drug Administration (FDA)–approved medications are effective treatments for helping tobacco users quit (3). Insurance coverage for tobacco cessation treatments is associated with increased quit attempts, use of cessation treatments, and successful smoking cessation (3); this coverage has the potential to reduce Medicaid costs (4). However, barriers such as requiring copayments and prior authorization for treatment can impede access to cessation treatments (3,5). As of July 1, 2016, 32 states (including the District of Columbia) have expanded Medicaid eligibility through the Patient Protection and Affordable Care Act (ACA),*,† which has increased access to health care services, including cessation treatments (5). CDC used data from the Centers for Medicare and Medicaid Services (CMS) Medicaid Budget and Expenditure System (MBES) and the Behavioral Risk Factor Surveillance System (BRFSS) to estimate the number of adult smokers enrolled in Medicaid expansion coverage. To assess cessation coverage among Medicaid expansion enrollees, the American Lung Association collected data on coverage of, and barriers to accessing, evidence-based cessation treatments. As of December 2015, approximately 2.3 million adult smokers were newly enrolled in Medicaid because of Medicaid expansion. As of July 1, 2016, all 32 states that have expanded Medicaid eligibility under ACA covered some cessation treatments for all Medicaid expansion enrollees, with nine states covering all nine cessation treatments for all Medicaid expansion enrollees. All 32 states imposed one or more barriers on at least one cessation treatment for at least some enrollees. Providing barrier-free access to cessation treatments and promoting their use can increase use of these treatments and reduce smoking and smoking-related disease, death, and health care costs among Medicaid enrollees (4,68).

A Healthy People 2020 objective (TU-8) calls for all state Medicaid programs to adopt comprehensive coverage of smoking cessation treatments.§ A previous study reported on state Medicaid coverage of cessation treatments during 2014–2015 in the population traditionally eligible for Medicaid coverage (9), but cessation coverage has not been reported among the population newly eligible for Medicaid expansion coverage in the 32 states (including the District of Columbia) that expanded Medicaid eligibility through ACA as of July 1, 2016. These states elected to expand coverage to a new eligibility group of adults aged <65 years known as the Medicaid expansion population (also known as the VIII group).

To estimate the number of adult cigarette smokers enrolled in Medicaid expansion coverage, 2014 BRFSS estimates of state-specific smoking prevalence among self-reported Medicaid enrollees were multiplied by MBES** enrollment data for December 2015. Newly eligible Medicaid enrollees were defined as persons who were newly enrolled in Medicaid because of ACA Medicaid expansion. Some states expanded Medicaid eligibility to varying extents before ACA was enacted. The overall Medicaid expansion population estimates (Table 1) include persons who enrolled in Medicaid because of these previous state expansion actions, as well as persons who enrolled in Medicaid because of state Medicaid expansions under ACA. The newly eligible Medicaid population estimates include the latter group only.

To assess cessation coverage available to the state Medicaid expansion population as of July 1, 2016, the American Lung Association collected data on coverage of, and barriers to accessing, all evidence-based cessation treatments except telephone counseling†† (a total of nine treatments) for state Medicaid expansion populations. The American Lung Association compiled data from Medicaid member websites and handbooks; Medicaid provider websites and handbooks; policy manuals; plan formularies and preferred drug lists; Medicaid state plan amendments; and relevant regulations and legislation. Personnel from state Medicaid agencies and health departments or other state government agencies were consulted to confirm the accuracy of collected information, retrieve missing documents, and reconcile discrepancies. Data were collected during July 19–August 18, 2016.

As of December 2015, approximately 3.3 million adult cigarette smokers were enrolled in Medicaid expansion coverage, including approximately 2.3 million adults who were newly eligible for Medicaid expansion coverage (Table 1). The number of adult smokers enrolled in Medicaid expansion coverage ranged from 2,567 in Alaska to 618,395 in New York; the number of newly eligible adult smokers enrolled in this coverage ranged from 2,567 in Alaska to 291,351 in Pennsylvania (Table 1).

As of July 1, 2016, nine of the 32 states that have expanded Medicaid eligibility (Colorado, Connecticut, Indiana, Massachusetts, Minnesota, North Dakota, Ohio, Pennsylvania, and Vermont) covered all nine cessation treatments for all Medicaid expansion enrollees (Table 2). Of the 32 states, 17 states covered individual counseling for all Medicaid expansion enrollees, 11 covered group counseling for all enrollees, and 19 covered all seven FDA-approved cessation medications for all enrollees. All 32 states imposed at least one barrier (e.g., copayments or prior authorization) on at least one treatment for at least some enrollees (Table 3). Six states required copayments for at least one cessation treatment for all enrollees, with an additional seven states requiring copayments for some enrollees. Twelve states required prior authorization to obtain at least one cessation treatment for all enrollees, with an additional 14 states requiring prior authorization for some enrollees.

Discussion

Under the Medicaid expansion provision of ACA, states can expand Medicaid eligibility to include adults aged <65 years with incomes ≤138% of the Federal Poverty Level.§§,¶¶ As of July 1, 2016, 32 states have expanded Medicaid eligibility, a step which has made Medicaid cessation coverage available to approximately 2.3 million adult smokers who were not previously eligible for Medicaid. Moreover, all of these states covered some cessation treatments for all Medicaid expansion enrollees, and 19 states covered all seven FDA-approved cessation medications for all enrollees. However, only nine states covered all nine cessation treatments, and all 32 states imposed one or more barriers to accessing cessation treatments for at least some enrollees. Several states, including Michigan and Minnesota, have made notable progress in removing barriers to cessation coverage for both their expansion and traditional (i.e., nonexpansion) Medicaid populations in recent years. Other states have made more recent progress in this regard. For example, Maryland removed copayments for cessation medications for enrollees in both expansion and traditional Medicaid, effective October 21, 2016. In September 2016, California enacted legislation requiring the state Medicaid program to cover a comprehensive cessation benefit for both the expansion and traditional Medicaid populations, effective January 1, 2017. Providing and promoting evidence-based cessation coverage has been found to be a cost-effective way to help smokers quit. Among the Medicaid population in Massachusetts, an evidence-based, heavily promoted Medicaid cessation benefit was associated with a reduction in smoking prevalence, from 38.3% to 28.3% over a 3-year period (7). For each dollar spent on the benefit over a 3-year period, an estimated $3.12 in medical savings occurred from averted cardiovascular hospitalizations alone (4).

With regard to tobacco cessation coverage, Medicaid expansion coverage is subject to different ACA provisions than traditional Medicaid coverage (5). Unlike traditional Medicaid coverage, Medicaid expansion coverage is subject to Section 1001 of ACA, which requires coverage without cost-sharing of preventive services receiving an A or B rating from the U.S. Preventive Services Task Force (USPSTF) (5). Tobacco cessation intervention has received an A-grade from USPSTF.***,††† Guidance issued by the departments of Health and Human Services, Labor, and Treasury in May 2014 defines how this provision applies to cessation coverage.§§§ To assist with compliance with Section 1001, CMS is contacting states to ensure that they understand the previous guidance and to provide technical assistance for states to achieve compliance. Several states that currently require copayments for some cessation treatments for Medicaid expansion enrollees have indicated that they are planning to remove this requirement.

More comprehensive state Medicaid coverage of cessation treatments is associated with increased use of cessation medications and increased quit rates among smokers enrolled in Medicaid (6,8). Moreover, removing barriers such as copayments, which pose a financial obstacle, and prior authorization, which can delay accessing services unless a process is in place to expedite authorization, further increases access to these treatments (3,5). Communicating to smokers and health care providers that cessation treatments are covered is also important to ensure that they are aware of and use covered treatments (5,7). A recent study found that only approximately 10% of Medicaid enrollees who smoked received a prescription for a tobacco cessation medication in 2013, with wide variation in use of cessation medications across states (10). Medicaid cessation coverage has the greatest effect when it is available to large numbers of smokers and is widely used (5,7).

The findings in this report are subject to at least four limitations. First, enrollment estimates were drawn from a new CMS reporting system whose primary purpose is to allow states to claim the enhanced Medicaid expansion federal matching rate; this system was missing information for seven expansion states for the assessment period. Second, the state smoking prevalence estimates were based on respondents who reported that they smoked and were enrolled in Medicaid; these estimates were not available for three states, and the relevant BRFSS question did not distinguish between traditional and Medicaid expansion coverage. In addition, 2014 smoking prevalence estimates were applied to December 2015 enrollment data to generate estimates of smokers enrolled in Medicaid expansion. Third, in cases where official coverage documents were not publicly available, were outdated, or conflicted with one another, state government personnel were consulted to provide additional documentation or resolve discrepancies; this information might be inaccurate in some cases. Finally, cessation coverage can vary widely across Medicaid expansion managed care plans, making it challenging to determine coverage.

The 32 states that have expanded Medicaid eligibility under ACA are providing Medicaid cessation coverage to approximately 2.3 million adult smokers who were not previously eligible for Medicaid. These states can take further steps toward helping these smokers quit by more fully covering cessation treatments, removing barriers to accessing covered treatments, making Medicaid enrollees and providers aware of these treatments, and monitoring use of these treatments (3,57). State Medicaid programs that take these actions can substantially reduce tobacco use and tobacco-related disease and health care costs among a vulnerable population (47). Opportunities exist for the 19 states that have not expanded Medicaid eligibility to reduce smoking among low-income adults by making their cessation coverage more broadly available. Providing barrier-free access to cessation treatments and promoting their use are important components of a comprehensive approach to reducing tobacco use (3,57).

Acknowledgments

Stephanie Bell, Sarah Delone, Kirsten Jensen, Deirdra Stockmann, Centers for Medicare & Medicaid Services; Paul G. Billings, Susan J. Rappaport, Kim Lacina, Erika Sward, Katherine Pruitt, Bill Blatt, Thomas Carr, Allison MacMunn, Gregg Tubbs, Ara Janoyan, Catherine Fields Chandler, Tenásha Williams, nationwide staff members, American Lung Association; Allison MacNeil, Lei Zhang, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.


Corresponding author: Stephen Babb, sbabb@cdc.gov, 770-488-1172.

1American Lung Association, Chicago, Illinois; 2Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.


* http://kff.org/health-reform/slide/current-status-of-the-medicaid-expansion-decision.

Coverage for the adult expansion population must be offered through an alternative benefit plan. States generally have expanded coverage in one of two ways: by extending traditional Medicaid coverage to the Medicaid expansion population or by creating a benefit package that is not aligned with the state’s traditional Medicaid state plan and using managed care for the expansion population. States can also provide subsidies to this population that are used to purchase coverage offered in the state or federally facilitated marketplace created by the Patient Protection and Affordable Care Act.

§ https://www.healthypeople.gov/2020/topics-objectives/topic/tobacco-use/objectives.

Data were obtained from the Behavioral Risk Factor Surveillance System (BRFSS) 2014 health care access module (http://www.cdc.gov/brfss/). Smoking prevalence estimates were calculated for 2014 BRFSS respondents aged 18–64 years who reported the following: 1) smoking ≥100 cigarettes during their lifetimes and smoking every day or some days at the time of the interview, and 2) having Medicaid or another state program as the primary source of their health care coverage. The relevant BRFSS question did not distinguish between traditional and expansion Medicaid coverage.

** https://www.medicaid.gov/medicaid-chip-program-information/program-information/medicaid-and-chip-enrollment-data/medicaid-enrollment-data-collected-through-mbes.html and http://kff.org/medicaid/issue-brief/an-overview-of-new-cms-data-on-the-number-of-adults-enrolled-in-the-aca-medicaid-expansion/.

†† Telephone cessation counseling is available free to callers to state quitlines (including Medicaid enrollees) in all 50 states and the District of Columbia through the national quitline portal 1-800-QUIT-NOW, and therefore is not included in this report. In June 2011, the Centers for Medicare & Medicaid Services (CMS) announced that it would offer a 50% federal administrative match to state Medicaid programs for the cost of state quitline counseling provided to Medicaid enrollees. Although not discussed in this report, some state Medicaid programs cover or otherwise provide access to telephone counseling for at least some Medicaid enrollees.

§§ http://housedocs.house.gov/energycommerce/ppacacon.pdf.

¶¶ Although a June 2012 Supreme Court ruling held that a state cannot lose federal funding for its existing Medicaid program if it does not participate in the expansion, financial incentives exist for all states to expand eligibility for Medicaid coverage (National Federation of Independent Business, et al. v. Kathleen Sebelius, Secretary of Health and Human Services, et al.; 132 S. Ct. 2566 [2012]).

*** https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions1.

††† The federal prohibition on cost-sharing for tobacco cessation services for the Medicaid expansion population in the new eligibility group for adults was explained in CMS guidance issued to state Medicaid agencies in 2012 (https://www.medicaid.gov/Federal-Policy-Guidance/downloads/SMD-12-003.pdf). CMS also issued an Information Bulletin in January 2016 on changes in Essential Health Benefit standards affecting Medicaid Alternative Benefit Plans, which reiterates the cost-sharing prohibition (https://www.medicaid.gov/federal-policy-guidance/downloads/cib-01-28-16.pdf).

§§§ https://www.dol.gov/ebsa/faqs/faq-aca19.html.

References

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Return to your place in the textTABLE 1. Estimated number of current smokers aged 18–64 years in Medicaid Expansion—32 states,* December 2015
State Adults enrolled in Medicaid Medicaid smoking prevalence Adult smokers in Medicaid expansion
Total no. No. in Medicaid expansion No. newly eligible
in Medicaid expansion†,§
Total no.** No. newly eligible**
Alaska 124,883 8,500 8,500 30.2 2,567 2,567
Arizona 1,873,397 412,957 105,711 30.4 125,622 32,157
Arkansas 919,768 291,602 266,741 NA NA NA
California NA NA NA NA NA NA
Colorado NA NA NA 27.4 NA NA
Connecticut 840,619 200,988 186,967 37.0 74,426 69,234
Delaware 210,636 60,006 9,280 37.4 22,460 3,474
District of Columbia 243,612 61,946 61,946 40.7 25,224 25,224
Hawaii 313,126 107,485 33,427 NA NA NA
Illinois 2,869,749 641,439 616,265 35.8 229,892 220,869
Indiana 1,244,321 361,687 222,364 48.3 174,550 107,313
Iowa 585,978 146,310 135,963 43.4 63,499 59,008
Kentucky 1,274,166 439,044 439,044 50.1 219,785 219,785
Louisiana 1,444,601 NA NA 35.9 NA NA
Maryland 1,061,749 231,484 231,484 30.3 70,140 70,140
Massachusetts 1,805,041 384,390 0 32.8 126,157 0
Michigan 2,287,620 613,761 579,378 40.9 250,844 236,792
Minnesota 1,186,498 208,492 207,683 32.6 68,031 67,767
Montana 138,970 NA NA 51.3 NA NA
Nevada NA NA NA 35.6 NA NA
New Hampshire 187,999 49,040 48,759 48.8 23,946 23,809
New Jersey NA NA NA 23.0 NA NA
New Mexico 840,108 235,425 235,425 30.4 71,522 71,522
New York 5,768,918 2,276,859 285,564 27.2 618,395 77,559
North Dakota NA NA NA 43.8 NA NA
Ohio 2,930,308 653,434 607,139 47.4 309,466 287,541
Oregon 1,055,080 518,904 452,269 35.8 185,768 161,912
Pennsylvania 2,670,350 603,335 547,962 53.2 320,793 291,351
Rhode Island 279,851 59,280 59,280 29.8 17,671 17,671
Vermont 207,146 60,678 0 36.8 22,323 0
Washington 1,813,800 592,114 577,422 34.2 202,562 197,536
West Virginia 554,210 174,999 174,999 48.9 85,627 85,627
Total 34,732,504 9,394,159 6,093,572 NR 3,311,270 2,328,858

Abbreviations: NA = not available; NR = not reported.
* Includes the District of Columbia.
Enrollment estimates were drawn from the Centers for Medicare and Medicaid Services Medicaid Budget and Expenditure System (MBES) CMS 64 Total Medicaid Enrollees – VIII Group Break Out Report, October–December 2015, Updated June 2016 (https://www.medicaid.gov/medicaid/program-information/downloads/cms-64-enrollment-report-oct-dec-2015.pdf). MBES was missing information for seven expansion states for the period in question.
§ The total VIII group category includes persons who enrolled in Medicaid because of actions in some states that expanded Medicaid eligibility before enactment of the Patient Protection and Affordable Care Act (ACA) and persons who enrolled in Medicaid because of state Medicaid expansions under ACA. The total VIII group newly eligible category only includes the latter group.
Data were obtained from the Behavioral Risk Factor Surveillance System (BRFSS) 2014 health care access module (http://www.cdc.gov/brfss/). Smoking prevalence estimates were calculated for 2014 BRFSS respondents aged 18–64 years who reported: 1) smoking ≥100 cigarettes during their lifetimes and smoking every day or some days at the time of the interview, and 2) having Medicaid or another state program as the primary source of their health care coverage. The relevant BRFSS question did not distinguish between traditional and expansion Medicaid coverage.
** BRFSS smoking prevalence estimates from 2014 were applied to December 2015 enrollment data to generate estimates of smokers with expansion Medicaid coverage. Although one decimal point prevalence estimates are reported here, two decimal point prevalence estimates were used in calculating the total and newly eligible numbers of smokers in the VIII group.

Return to your place in the textTABLE 2. Medicaid expansion coverage of tobacco cessation treatments — 32 states,* July 1, 2016
State Treatment
Individual counseling Group counseling Nicotine patch Nicotine gum Nicotine lozenge Nicotine nasal spray Nicotine inhaler Bupropion Varenicline
Alaska Yes No Yes Yes Yes Yes Yes Yes Yes
Arizona No No Yes Yes Yes Yes Yes Yes Yes
Arkansas V No V V V V V Yes Yes
California V V Yes Yes Yes V V Yes Yes
Colorado Yes Yes Yes Yes Yes Yes Yes Yes Yes
Connecticut Yes Yes Yes Yes Yes Yes Yes Yes Yes
Delaware Yes No Yes Yes Yes Yes Yes Yes Yes
District of Columbia NA NA Yes Yes Yes V V Yes Yes
Hawaii Yes V Yes Yes V V V Yes Yes
Illinois No No Yes Yes Yes Yes Yes Yes Yes
Indiana Yes Yes Yes Yes Yes Yes Yes Yes Yes
Iowa V V Yes Yes Yes Yes Yes Yes Yes
Kentucky V V Yes Yes Yes Yes Yes Yes Yes
Louisiana No V V V V Yes Yes Yes Yes
Maryland Yes No Yes Yes Yes Yes Yes Yes Yes
Massachusetts Yes Yes Yes Yes Yes Yes Yes Yes Yes
Michigan V V Yes Yes Yes Yes Yes Yes Yes
Minnesota Yes Yes Yes Yes Yes Yes Yes Yes Yes
Montana Yes No Yes Yes Yes Yes Yes Yes Yes
Nevada No V V V V Yes Yes Yes Yes
New Hampshire V No V V V Yes Yes Yes Yes
New Jersey V V Yes V Yes V V Yes Yes
New Mexico V V Yes Yes Yes V V Yes Yes
New York Yes Yes Yes Yes V V V Yes V
North Dakota Yes Yes Yes Yes Yes Yes Yes Yes Yes
Ohio Yes Yes Yes Yes Yes Yes Yes Yes Yes
Oregon V V Yes Yes V V V Yes Yes
Pennsylvania Yes Yes Yes Yes Yes Yes Yes Yes Yes
Rhode Island Yes Yes Yes Yes Yes V V Yes Yes
Vermont Yes Yes Yes Yes Yes Yes Yes Yes Yes
Washington Yes No Yes Yes Yes Yes Yes Yes Yes
West Virginia No No Yes Yes V V V Yes V
Totals
Yes 17 11 28 27 24 22 22 32 30
No 5 10 0 0 0 0 0 0 0
V 9 10 4 5 8 10 10 0 2
NA 1 1 0 0 0 0 0 0 0

Abbreviations: NA = not available; V = varies by plan.
* Includes the District of Columbia.

Return to your place in the textTABLE 3. Barriers to Medicaid expansion coverage of tobacco cessation treatments — 32 states,* July 1, 2016
State Copayments required Prior authorization required Counseling required for medications Stepped-care therapy§ Limits on duration Annual limits on quit attempts Lifetime limits on quit attempts
Alaska Yes Yes No No Yes Yes No
Arizona No No No No Yes Yes No
Arkansas V V No No V V No
California No V No V V V No
Colorado V V V No Yes Yes No
Connecticut No Yes No No No Yes No
Delaware Yes Yes Yes Yes Yes Yes No
District of Columbia No V No No V V No
Hawaii No V V V V Yes No
Illinois Yes No No No No No No
Indiana No Yes V V Yes Yes No
Iowa No Yes Yes Yes Yes Yes No
Kentucky No Yes No V Yes Yes No
Louisiana V V V V V V No
Maryland NA Yes No Yes No Yes No
Massachusetts Yes Yes No No No Yes No
Michigan No No No No V No No
Minnesota No NA No No V No No
Montana No Yes No NA NA NA No
Nevada No Yes No V Yes Yes No
New Hampshire V No No No V V No
New Jersey No V No V No V V
New Mexico No V V No V V No
New York Yes V No V Yes Yes No
North Dakota No No No No Yes Yes No
Ohio V V No V V V No
Oregon No V V V V V No
Pennsylvania V V No No Yes Yes No
Rhode Island No Yes V V Yes Yes No
Vermont Yes Yes No Yes Yes Yes No
Washington No V V V Yes Yes No
West Virginia V V V No V V No
Totals
Yes 6 12 2 4 14 18 0
No 18 5 21 15 5 3 31
V 7 14 9 12 12 10 1
NA 1 1 0 1 1 1 0

Abbreviations: NA = not available; V = varies by plan.
* Includes the District of Columbia.
Barriers apply to one or more cessation treatments.
§ Refers to a requirement that a person try and fail to quit with one cessation medication before being able to access another cessation medication.

Suggested citation for this article: DiGiulio A, Haddix M, Jump Z, et al. State Medicaid Expansion Tobacco Cessation Coverage and Number of Adult Smokers Enrolled in Expansion Coverage — United States, 2016. MMWR Morb Mortal Wkly Rep 2016;65:1364–1369. DOI: http://dx.doi.org/10.15585/mmwr.mm6548a2.

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