States that fail to expand Medicaid eligibility in the wake of the Affordable Care Act will shoulder a greater public burden related to smoking, according to a study published in Health Affairs. The researchers also concluded that Medicare and public health agencies should be working together to make smoking cessation a priority for beneficiaries.
“Medicaid enrollees are about twice as likely to be current smokers (32%) as the general U.S. population (17%), based on our analysis of 2014 data from the National Health Interview Survey,” Leighton Ku, PhD, professor of health policy and management, and director of the Center for Health Policy Research at George Washington University in Washington, D.C., and colleagues wrote. “A recent surgeon general’s report estimated that 15% of all Medicaid expenditures are attributable to smoking — an amount equal to about $40 billion in 2010. Given projected program growth, the cost of smoking-related diseases in Medicaid alone could rise to more than $75 billion by 2016 (author’s estimate).”
In assessing the effectiveness of state Medicaid programs in smoking cessation, the researchers analyzed beneficiaries’ use of tobacco-cessation medications from 2010 to 2013. Focusing on FDA-approved tobacco cessation medications — nicotine replacement therapies, bupropion and Chantix (varenicline, Pfizer) — the researchers accessed Medicaid drug usage files from CMS, which includes data state Medicaid agencies must submit quarterly to receive their rebates. The main unit of analysis for tobacco cessation usage was a prescription refill.
In addition, the researchers estimated smoking status using the CDC’s Behavioral Risk Factor Surveillance System (BRFSS), which reports the percentage of low-income — defined as earning less than $20,000 annually — insured adults who are smokers in each state. To estimate the number of adult Medicaid beneficiaries who smoked during 2010 through 2013, they multiplied the percentage of low-income insured smokers in each state by the number of adult Medicaid enrollees in December of each year. Based on their own research, as well as previous CDC analysis, the investigators assumed that a typical Medicaid smoker received two prescriptions per year.
According to the researchers, approximately 10% of adult smokers enrolled in Medicaid received tobacco cessation medications each year, or about 830,000 people in 2013. In addition, Medicaid programs in 2013 spent $103 million on cessation medications, less than 0.25% of the estimated cost of smoking-related diseases to Medicaid. While every state Medicaid program covers cessation benefits, the use of such medications varies greatly, with a more than thirtyfold difference between the state with the highest usage rate, Minnesota, and Texas, the state with the lowest. Nationwide, 30% of adult Medicaid enrollees smoke and have an average usage rate of 0.2 prescription per smoker per year, leading the researchers to determine that 10% of beneficiaries who smoke have received cessation medication. In states that have expanded Medicaid following the Affordable Care Act, an average of 25% of adult enrollees smoke, with a cessation medication usage rate of 0.23 per smoker. Meanwhile, in states that have not expanded Medicaid, 32% of adult beneficiaries are smokers, and the cessation medication usage rate is 0.14 per smoker.
“The fundamental challenges are informing health care providers and patients about the importance of stopping smoking and engaging them in cessation efforts, making medications and counseling available, and developing innovative strategies to help patients change their behavior,” Ku and colleagues wrote. “As the U.S. health system seeks to focus on population health, Medicaid and public health agencies can make important contributions to efforts to improve health and lower health costs by preventing smoking in the first place and helping those who smoke to quit.” – by Jason Laday
Disclosure: The authors report receiving a grant from the National Cancer Institute to fund this study.