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Medicaid expansion under ACA linked to higher rate of smoking cessation

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PITTSBURGH, Nov. 13, 2017 – When low-income adults were newly covered by Medicaid under the Affordable Care Act (ACA), they were more likely to quit smoking cigarettes than their counterparts in states that did not offer Medicaid expansion, according to a new analysis from the University of Pittsburgh Graduate School of Public Health.

The findings, published online and scheduled for an upcoming issue of the journal Medical Care, support a policy-driven approach to reduce high smoking rates among low-income adults by giving greater access to smoking cessation programs.

"Smoking cessation is notoriously difficult to achieve," said senior author Marian Jarlenski, Ph.D., M.P.H., assistant professor in Pitt Public Health's Department of Health Policy and Management. "The sizable increase we found in smoking cessation might lead to significant reductions in death and diseases caused by smoking, and the taxpayer-funded health care expenditures that come with treating them."

Smoking is responsible for 9 percent of annual health care spending in the U.S., and 30 percent of low-income adults smoke cigarettes, double that of the U.S. average.

The ACA provided states the opportunity to expand Medicaid coverage to all low-income people at or below 138 percent of the federal poverty level. As part of the expansion, the state Medicaid programs were required to offer smoking cessation services.

Jarlenski and lead author J. Wyatt Koma, B.S., a recent graduate of Pitt's Honors College, analyzed answers from more than 36,000 low-income adults ages 18 to 64 without dependent children to an annual telephone survey of health behaviors administered by the Centers for Disease Control and Prevention. They then compared the answers to smoking-related questions among residents in the 31 states that had expanded Medicaid coverage with residents in the states that had not.

In the states with Medicaid expansion, 8.1 percent of the newly covered low-income adults reported that they'd quit smoking in the prior year, compared with 6 percent of low-income adults in the states without expansion. This was after the researchers took into account the effect on smoking rates of demographics, as well as differences in cigarette taxes and state indoor clean air laws.

"There are many explanations for why new Medicaid enrollees may be motivated to quit smoking when they engage with health care services," said Koma, now a research assistant in health care with NORC at the University of Chicago. "During the Medicaid enrollment process, people are asked whether they smoke, so it's possible that this question might prompt them to start contemplating smoking cessation. After enrollment, they have access to primary care visits, where their clinician is likely to counsel them about quitting. And studies have shown that people in states with Medicaid expansion are much more likely to get prescriptions for smoking cessation medications, which are covered by Medicaid."

However, Koma went on to note that the 8.1 percent rate of smoking cessation is still low, especially compared to the 68.9 percent of adults who say they want to quit.

"The question remains whether or not there will be sufficient funds and support to continue to improve the health outcomes of these vulnerable populations moving forward," he said.

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Additional authors on this research are Julie M. Donohue, Ph.D., of Pitt Public Health; Colleen L. Barry, Ph.D., M.P.P., of Johns Hopkins University; and Haiden A. Huskamp, Ph.D., of Harvard University.

This research was funded by the Pitt Honors College Chancellor's Research Fellowship and the National Institutes of Health's Building Interdisciplinary Research Careers in Women's Health program grant K12HD043441.

About the University of Pittsburgh Graduate School of Public Health

The University of Pittsburgh Graduate School of Public Health, founded in 1948 and now one of the top-ranked schools of public health in the United States, conducts research on public health and medical care that improves the lives of millions of people around the world. Pitt Public Health is a leader in devising new methods to prevent and treat cardiovascular diseases, HIV/AIDS, cancer and other important public health problems. For more information about Pitt Public Health, visit the school's Web site at http://www.publichealth.pitt.edu.

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http://dx.doi.org/10.1097/MLR.0000000000000821

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