State Medicaid programs have steadily increased coverage of tobacco dependence treatments since the mid-1990s, the National Cancer Institute’s Cancer Trends Progress Report – 2009/2010 Update noted. Medicaid is a health insurance program run by federal and state governments for people who cannot afford regular medical care. In 1995, only three state Medicaid programs covered tobacco dependence treatments, but by 2006, 42 states and the District of Columbia covered some form of treatment. Two more states added coverage in 2007.
The increased access to tobacco dependence treatments is significant since the cigarette smoking rate among adult Medicaid recipients is higher than that of the general adult population—33 percent compared to 20 percent—according to the Centers for Disease Control and Prevention (CDC). Smoking is estimated to cause about one-third of all cancer deaths, and quitting smoking reduces cancer risk. For example, 10 years after quitting smoking a person’s risk of lung cancer decreases to about one-third to one-half the risk of a person who continues to smoke. Lung cancer risk decreases further the longer a person abstains from smoking, the Cancer Trends Progress Report noted.
In a commentary for the February 2009 edition of The Oncologist, three NCI leaders, James H. Doroshow, M.D., director of the NCI Division of Cancer Treatment and Diagnosis; John E. Niederhuber, M.D, director of the NCI; and Robert T. Croyle, Ph.D., director of the NCI Division of Cancer Control and Population Sciences, wrote, “Reducing tobacco use—the nation’s leading cause of cancer death—remains the greatest unmet potential for improving control of cancer and many other chronic diseases.” The NCI leaders emphasized that the disparities of tobacco use by education level and income, as well as by race and ethnicity, contribute “heavily to the health disparities that so burden our nation.”
Treatment Coverage Varies by State
The types of tobacco dependence treatments covered by Medicaid vary by state. Forty-one states cover some form of pharmacotherapy (for example, prescription medications such as bupropion, marketed as Zyban, and varenicline, marketed as Chantix, as well as over-the-counter nicotine replacement products). Twenty-six states cover some form of tobacco-cessation counseling (group, individual, or telephone). Twenty-three states cover some form of medication and at least one type of counseling (four cover medication for all enrollees but counseling for pregnant women only). Two states cover treatment (medication and counseling or counseling alone) for pregnant women only. The U.S. Food and Drug Administration (FDA) has approved seven medications (prescription and over-the-counter) for treating tobacco dependence, and 25 states provide coverage for all FDA-approved medications. Only one state, Oregon, provides coverage for all treatments recommended in the Public Health Service’s Clinical Practice Guidelines, which include individual, group, and telephone counseling, along with tobacco dependence medications.
Although a treatment may be covered, there are often restrictions. For example, some states require copayments, limit the number of treatment courses, or disallow combined treatments.
Despite the increase in the number of states covering tobacco dependence treatments over the past two decades, knowledge among Medicaid enrollees that treatments are covered remains low. A 2006 study published in the American Journal of Preventive Medicine found that less than half (46 percent) of Medicaid enrollees who were smokers or recent quitters knew that their state Medicaid program covered at least one form of tobacco dependence treatment. Fewer (41 percent) knew of pharmacotherapy coverage for quitting tobacco.
Studies have found that behavioral counseling and medication, each effective alone, are more effective when used together, the Cancer Trends Progress Report noted. According to the report however, “most people attempting to quit do not make use of these evidence-based strategies. Increasing the proportion of smokers that use evidence-based interventions holds great promise for decreasing the overall prevalence of smoking.”
Economic Costs of Tobacco Dependence
Smoking-related Medicaid costs vary widely by state. In 2004, for example, these costs ranged from $40 million in Wyoming to $3.3 billion in the state of New York. In total, smoking-related Medicaid expenditures for all states combined was $22 billion, which represented 11 percent of all Medicaid spending in 2004. Total state and federal Medicaid expenditures were $298 billion in 2004; the total increased to $353 billion by 2008.
Approximately $193 billion in annual health-related economic losses in the United States are due to cigarette smoking, including $96 billion in direct medical costs and $97 billion in lost productivity. The direct medical costs and lost productivity of smoking is an estimated $10.47 per pack of cigarettes, while the average U.S. retail price of a pack of cigarettes was $4.35 in 2008, according to the CDC’s Smoking and Tobacco Use Fact Sheet.
What is Medicaid?
Medicaid is a state-administered program jointly funded by federal and state governments available to certain low-income individuals and families with low incomes and resources. In addition, eligibility is based on whether a person is aged, disabled, a child, a parent of Medicaid-eligible dependent children, or a pregnant woman.
States are able to set income eligibility at higher levels than federal minimum requirements, resulting in wide variations in the percentage of low-income populations enrolled in Medicaid. As of 2004, Medicaid on average covered 8 percent of non-elderly adults in the U.S. and 26 percent of children. While federal law requires coverage of certain mandatory medical services, states have flexibility to cover many other optional benefits.
Under the Patient Protection and Affordable Care Act, or health reform, passed in March 2010, states have the option to expand Medicaid eligibility to adults without children beginning April 1, 2010. Starting in 2014, all low-income, non-elderly and non-disabled individuals will be eligible for Medicaid. The expanded coverage includes all people with income below $29,000 for a family of four (currently 133 percent of poverty).
To finance the extension of coverage, the federal government will support states by providing 100 percent of the cost of newly eligible people between 2014 and 2016, stepping down to 93 percent of the costs by 2019, and 90 percent matching for subsequent years.
- Armour BS, Finkelstein EA, Fiebelkorn IC. State-level Medicaid Expenditures Attributable to Smoking. Preventing Chronic Disease, 2009;6(3). http://www.cdc.gov/pcd/issues/2009/jul/08_0153.htm.
- Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Review. November 6, 2009. State Medicaid Coverage for Tobacco-Dependence Treatments—United States, 2007. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5843a1.htm
- Centers for Disease Control and Prevention. Smoking and Tobacco Use Fact Sheet. Link
- Centers for Medicare and Medicaid. National Health Expenditures Data Projected. Link
- Clinical Practice Guideline Treating Tobacco Use and Dependence. http://www.surgeongeneral.gov/tobacco/treating_tobacco_use.pdf
- Congressional Budget Office. The Long-Term Outlook for Medicare, Medicaid, and Total Health Care Spending. http://www.cbo.gov/ftpdocs/102xx/doc10297/Chapter2.5.1.shtml
- Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Historical and Projected Trends in Medicaid, October 2006. http://aspe.hhs.gov/health/reports/06/trendsinmedicaid/report.pdf
- Doroshow JH, Croyle RT, Niederhuber JE. Five Strategies for Accelerating the War on Cancer in an Era of Budget Deficits. The Oncologist, 2009:14(2). http://theoncologist.alphamedpress.org/cgi/content/full/14/2/110
- McMenamin, SB, Halpin, HA, Bellows, NM. Knowledge of Medicaid Coverage and Effectiveness of Smoking Treatments. American Journal of Preventive Medicine 2006:31(5).
- National Cancer Institute Cancer Trends Progress Report – 2009/2010 Update. http://progressreport.cancer.gov
- The White House. Summary of Key Elements of Health Reform. http://www.whitehouse.gov/health-care-meeting/proposal
For More Information
- National Cancer Institute. Free Help to Quit Smoking. http://www.cancer.gov/cancertopics/smoking
- Centers for Medicare and Medicaid Services. Medicaid Program—General Information. http://www.cms.hhs.gov/MedicaidGenInfo/
- U.S. Food and Drug Administration. Smoking Cessation Products to Help You Quit. http://www.fda.gov/TobaccoProducts/ResourcesforYou/ucm168231.htm