Helping Smokers Quit: Opportunities Created by the Affordable Care Act

In its review of tobacco dependence treatments, the 2008 United States Public Health Service Clinical Practice Guideline concluded, “Indeed, it is difficult to identify any other condition that presents such a mix of lethality, prevalence, and neglect, despite effective and readily available interventions.”¹ The low utilization of clinical interventions by both smokers and physicians alike is partly due to inadequate insurance coverage.^{1, 2} Many health insurers still fail to cover the evidence-based counseling and medication treatments recommended in the 2008 Guideline.² Even when these treatments are covered, barriers to utilization such as copayments and prior authorization requirements make accessing them costly and inconvenient.² Further, complex, unclear, and variable tobacco cessation coverage can be confusing for both physicians and patients, making it harder for physicians to help patients quit smoking.²

Improved coverage of cessation treatments increases quit attempts, treatment use, and successful quitting.¹ In particular, coverage that reimburses cessation interventions may increase the chances that physicians will intervene with smokers. Methods that rapidly and easily connect smokers with cessation treatment resources also increase treatment utilization and cessation.¹

Several provisions in the Affordable Care Act are designed to address the longstanding gap in cessation coverage and thereby increase cessation. While these provisions have received little publicity, they have the potential to contribute greatly to fulfilling the Act’s goals of improving the quality of health care and achieving better health outcomes while reducing health care costs.

One major provision of the Act requires most private health plans to cover, without cost-sharing, preventive services that have received an A or B grade from the U.S. Preventive Services Task Force. This includes tobacco cessation interventions.

On May 2, 2014, the Departments of Health and Human Services, Labor, and the Treasury jointly issued guidance for insurers on cessation coverage (see http://www.dol.gov/ebsa/faqs/faq-aca19.html). This guidance, which is based on the 2008 Guideline,¹ stated that insurers would be in compliance if they covered, without cost-sharing or prior authorization, two quit attempts a year, including both counseling and medication (Figure). Prior to this guidance, the specifics of how insurers were expected to implement the Affordable Care Act’s preventive services provisions mandating tobacco cessation coverage had not been defined, and coverage had varied widely.

Figure.

Adapted from http://www.dol.gov/ebsa/faqs/faq-aca19.html

If fully implemented, this guidance should substantially increase tobacco users’ access to proven cessation treatments, helping thousands of smokers quit. Physicians, insurer associations, and state health and insurance officials can play a key role in ensuring that health plans and insurers are aware of and follow this new guidance. If all insurers provide such coverage, all will benefit when members quit, even when individuals switch plans.

The Affordable Care Act also includes important provisions regarding cessation coverage for Medicaid and Medicare smokers. Medicaid enrollees smoke at especially high rates, and smoking-related disease is a major factor driving increasing Medicaid costs. Research suggests that more comprehensive state Medicaid coverage for cessation treatments is associated with increased quit rates.³ However, state Medicaid coverage of cessation treatments varies widely. The Act’s requirement that insurers cover certain specific preventive services with no cost-sharing applies to newly eligible Medicaid beneficiaries in states that opt to expand Medicaid, but not to beneficiaries with traditional Medicaid coverage. A separate provision bars states from excluding FDA-approved cessation medications from traditional Medicaid coverage. If states fully implement this provision, it could substantially improve access to cessation treatments for Medicaid smokers. Another provision requires traditional state Medicaid coverage to include a comprehensive cessation benefit for pregnant women; this provision has increased state Medicaid coverage of cessation counseling and medications for this population.⁴ The Act also eliminates cost-sharing for cessation treatments for asymptomatic Medicare recipients.

Finally, a provision of the Affordable Care Act allows some health insurers to charge tobacco users premiums up to 50% higher than those charged nontobacco users. The Act requires insurers in the small group market to waive the increased premium if smokers participate in a cessation program. While imposing higher premiums on tobacco users might motivate them to quit, it could also cause them to conceal their tobacco use, avoid seeking cessation assistance, or forego health insurance.⁵ Such unintended consequences may be more likely in the absence of comprehensive cessation coverage. It will be important for health insurers, employers, and federal and state health authorities to closely monitor the implementation and effects of this provision. If negative effects become evident, states have authority to prohibit insurers from charging tobacco users higher premiums or reduce the maximum allowable surcharge increase. At least six states and the District of Columbia have already barred insurers from imposing higher premiums on smokers (http://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/state-rating.html).

The Affordable Care Act has the potential to dramatically increase coverage of evidence-based cessation treatments and make these treatments available to millions of Americans. However, the potential benefits of this Act will only be realized if both smokers and physicians are aware of the opportunities it affords. Promotion was one key to the impressive outcomes of the 2006 Massachusetts Medicaid cessation benefit. Over a three year period, the benefit was used by 37% of smokers on Medicaid (i.e., more than 70,000 smokers),³ the smoking rate among state Medicaid enrollees fell from 38% to 28%,³ heart attack hospitalizations fell by almost half and $3.12 in medical savings for was realized for every dollar spent on the benefit. Promotional activities also prompt increased quit attempts even in smokers not using cessation assistance by normalizing quitting and reassuring smokers that help is available should they need it. Physicians, joined by public health organizations, can play a vital role in making patients and health care organizations aware of expanded cessation coverage.

Comprehensive, barrier-free, widely promoted tobacco cessation coverage makes it easier for smokers to quit and for physicians to help them quit. By covering and promoting proven cessation treatments, insurers can reduce smoking rates, smoking-related disease, and health care costs. Over time, such coverage could accelerate the end of the tobacco epidemic. If the Affordable Care Act’s tobacco cessation provisions are fully implemented, they could turn out to be one of its greatest legacies.