Smoking in America: Medicaid, Quitting, and Income

Over the last few decades, cigarette smoking has become a health burden concentrated primarily among low-income individuals in the U.S. In our recently published research study, Medicaid coverage expansions and cigarette smoking cessation among low-income adults, we sought to determine the relationship between recent expansions of Medicaid coverage and smoking cessation for low-income adults.

Demographics of Smoking

The question of who smokes is largely explained by income. Even after decades of public health efforts to reduce cigarette use, nearly 15% of the U.S. adult population continues to smoke. However, the prevalence of smoking among low-income adults is double the prevalence nationally, as 30% of low-income adults are smokers.

These smoking disparities contribute to pervasive inequities in health among adults with low socioeconomic status, both in the U.S. and globally. Low-income smokers disproportionately shoulder the burden of smoking-related diseases. From 2009-2013, U.S. counties with the lowest levels of education attainment or highest poverty rates had the highest tobacco-related cancer incidence and death rates.  The burden of this prevalence is borne out in smoking-related diseases, which are costly for the U.S. health care system, as smoking is responsible for 9% of annual healthcare spending. The burden of financing this excess healthcare due to smoking falls largely on public payers, such as Medicaid.

Access to Healthcare under the Affordable Care Act

The ACA provided states the opportunity to expand Medicaid coverage to all low-income individuals (at or below 138% of federal poverty level), including those without either dependent children or disabilities. Numerous peer-reviewed research studies have documented the extent to which the ACA has increased coverage and access to care for low-income adults. As part of the ACA expansion, state Medicaid programs were required to cover smoking cessation benefits for newly eligible adults without cost sharing. These cessation benefits include access to both provider counseling and smoking cessation pharmacotherapies. Our study is the first to use national data to determine if Medicaid coverage expanded under the ACA was associated with smoking cessation among newly-insured, low-income adults.

Evaluating Smoking Cessation under the ACA

It is crucial to empirically evaluate the effects of the ACA to inform health policymakers of evidence regarding the implementation and impact of specific provisions of the ACA. Prior commentary has suggested that the ACA should increase smoking cessation via more comprehensive insurance coverage of cessation treatments.

Our study population included non-elderly adults without dependent children who had incomes <138% of poverty and reported smoking at any time in the past year.

We first assessed if the ACA was associated with gains in coverage and access to care over time in our study sample. These newly-eligible, low-income adults residing in states that chose to expand Medicaid (Expansion states) had consistently higher rates of insurance coverage, relative to states that chose not to expand Medicaid (Non-expansion states).

Similarly, low-income adults living in expansion states reported significantly fewer barriers to health care due to cost, relative to similar adults in non-expansion states. Given that this population of newly-eligible adults who smoked in the past year were reporting higher insurance coverage and access to care, we then used an econometric model to evaluate the effect of states’ decisions to expand Medicaid on the probability of reporting recent smoking cessation, defined as having quit in the past year and not having smoked for at least one month.

Our results were significant. We found that there was a sizable increase in the probability of recent smoking cessation associated with a state’s decision to expand Medicaid to low-income adults. This study provides the first empirical evidence suggesting that expanding Medicaid coverage under the Affordable Care Act to low-income adults led to a significant increase in smoking cessation, long considered an immutable health behavior.

Implications for Policy

Smoking cessation is difficult to achieve. The persistent income disparities in smoking cessation over time have led to a belief that smoking behaviors among low-income populations are more difficult to change than among higher income groups. However, the root of the smoking disparity is likely less a function of income – there is no reason to believe that the addictiveness of cigarettes varies by income – and more a question of equitable access to evidence-based smoking cessation services.

Our research has shown that when newly-eligible, low-income adults are covered by Medicaid, they are more likely to access and utilize smoking cessation benefits and potentially quit smoking. Findings from this study reinforce the importance of Medicaid in providing access to care to low-income adults. We also note, however, that overall rates of recent smoking cessation remain low, with 8% of adults reporting recent smoking cessation, compared to an estimated 68.9% of current, daily smokers who say they want to quit.  With increased access to care comes increased preventive care and smoking cessation, which are necessary to end health disparities driven by socioeconomic status. Given the results of our study linking coverage to access and outcomes for low-income adults, 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.

J Wyatt Koma

J Wyatt Koma

J. Wyatt Koma, B.S., is a recent graduate of the University of Pittsburgh, where he studied Neuroscience. Wyatt’s interests include measuring access to health care in a changing U.S. policy environment; and ways to decrease modifiable behavioral health risks, such as cigarette smoking, in low-income populations.
J Wyatt Koma
J Wyatt Koma

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Marian Jarlenski

Marian Jarlenski

Marian Jarlenski, PhD, MPH, is an Assistant Professor in the Department of Health Policy and Management in the University of Pittsburgh Graduate School of Public Health. Her research seeks to advance knowledge about how health policies affect access to care, clinical practice, and health behaviors that ultimately affect maternal and child health outcomes. Current work focuses on how health policies can be optimized to improve the health of women who use substances in the perinatal period. Dr. Jarlenski is an expert in Medicaid policy and is interested in the politics of health policy. She earned a PhD from the Johns Hopkins Bloomberg School of Public Health, an MPH from the Yale School of Public Health, and a BA from Otterbein College.
Marian Jarlenski

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Cheryl Austein Casnoff

Cheryl Austein Casnoff

Cheryl Austein Casnoff is a Senior Fellow in both of NORC's health research departments, Health Care and Public Health. She has had a distinguished public service career in public health, health financing and health IT, and brings a deep understanding of federal, state, local, and tribal government public health and health systems policies. Highlights of her career include establishing and leading a new Office of Health Information Technology (OHIT) within the Health Resources and Services Administration (HRSA) to work with health center grantees across the country to promote the adoption and meaningful use of electronic health records. Austein Casnoff was also instrumental in designing and implementing the original $40 billion Children's Health Insurance Program (CHIP). As the Director of CHIP and the Director of Benefits, Coverage and Policy for CMCS, she worked with states and regional offices to ensure the timely, efficient approval of Medicaid and CHIP state plans, waivers, and demonstrations including early efforts to promote innovative outreach, enrollment and retention of children in Medicaid and CHIP. As the director of Public Health Policy in the Office of the Assistant Secretary for Planning and Evaluation (ASPE) for almost two decades, Austein Casnoff directed numerous research and policy studies and task forces on critical HHS topics in public health and financing policy. She also has extensive expertise in preparing reports and conducting briefings for senior HHS and OMB officials as well as Congress.
Cheryl Austein Casnoff

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