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Medicaid Coverage Expansions and Cigarette Smoking Cessation Among Low-income Adults.

ABSTRACT: Expanding Medicaid coverage to low-income adults may have increased smoking cessation through improved access to evidence-based treatments. Our study sought to determine if states' decisions to expand Medicaid increased recent smoking cessation.Using pooled cross-sectional data from the Behavioral Risk Factor Surveillance Survey for the years 2011-2015, we examined the association between state Medicaid coverage and the probability of recent smoking cessation among low-income adults without dependent children who were current or former smokers (n=36,083). We used difference-in-differences estimation to examine the effects of Medicaid coverage on smoking cessation, comparing low-income adult smokers in states with Medicaid coverage to comparable adults in states without Medicaid coverage, with ages 18-64 years to those ages 65 years and above. Analyses were conducted for the full sample and stratified by sex.Residence in a state with Medicaid coverage among low-income adult smokers ages 18-64 years was associated with an increase in recent smoking cessation of 2.1 percentage points (95% confidence interval, 0.25-3.9). In the comparison group of individuals ages 65 years and above, residence in a state with Medicaid coverage expansion was not associated with a change in recent smoking cessation (-0.1 percentage point, 95% confidence interval, -2.1 to 1.8). Similar increases in smoking cessation among those ages 18-64 years were estimated for females and males (1.9 and 2.2 percentage point, respectively).Findings are consistent with the hypothesis that Medicaid coverage expansions may have increased smoking cessation among low-income adults without dependent children via greater access to preventive health care services, including evidence-based smoking cessation services.

SUBMITTER: Koma JW

PROVIDER: S-EPMC5688008 | biostudies-literature | 2017 Dec

REPOSITORIES: biostudies-literature

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Medicaid Coverage Expansions and Cigarette Smoking Cessation Among Low-income Adults.

Koma Jonathan W JW Donohue Julie M JM Barry Colleen L CL Huskamp Haiden A HA Jarlenski Marian M

Medical care 20171201 12

<h4>Introduction</h4>Expanding Medicaid coverage to low-income adults may have increased smoking cessation through improved access to evidence-based treatments. Our study sought to determine if states' decisions to expand Medicaid increased recent smoking cessation.<h4>Methods</h4>Using pooled cross-sectional data from the Behavioral Risk Factor Surveillance Survey for the years 2011-2015, we examined the association between state Medicaid coverage and the probability of recent smoking cessation ...[more]

PMID: 29068908

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Project description:ImportanceThe Affordable Care Act created 2 new coverage options for uninsured adults: Medicaid expansion, which in most states provides comprehensive coverage without premiums and deductibles; and private marketplace coverage, which requires a premium contribution and cost-sharing, though with generous federal subsidies at lower incomes. How enrollment rates compare in the marketplace vs Medicaid is an important policy question as states continue to weigh alternative coverage options such as Medicaid buy-in programs, enrolling Medicaid-eligible populations into marketplace plans, or creating a public option.ObjectiveTo assess the association between income eligibility for Medicaid vs marketplace coverage and insurance enrollment among low-income adults in Colorado.Design setting and participantsUsing 2014 and 2015 all-payer claims data from Colorado and detailed income eligibility information, we used a regression discontinuity design to assess the difference in Medicaid and marketplace enrollment just below and just above 138% of the federal poverty level (FPL), the eligibility threshold between the 2 programs. The sample included nonpregnant adults aged 19 to 64 years with incomes between 75% to 400% FPL. We stratified our analysis by age, sex, chronic condition status, and urban vs rural residence. Analysis was conducted from January to October 2020.Main outcome and measuresThe main outcome was total enrollment in either Medicaid or marketplace coverage during marketplace's Open Enrollment period. Income-based health insurance eligibility was assessed as a percentage of FPL at the time of initial application for coverage.ResultsThe primary analytical sample included 32 091 enrollees in 2014 and 55 451 in 2015, with incomes ranging from 120% to 156% FPL. Most enrollees were women (59.26% in 2014, 59.20% in 2015), resided in urban areas (70.36% in 2014, 73.08% in 2015), and had no chronic conditions (74.66% in 2014, 76.11% in 2015). For age, in 2014 and 2015, respectively, 13.22% and 13.93% were aged 19 to 25 years, 27.85% and 28.54% were aged 26 to 34 years, 23.58% and 24.34% were aged 35 to 44 years, 18.35% and 17.75% were aged 45 to 54 years, and 17.00% and 15.44% were aged 55 to 64 years. Marketplace enrollment was 81.3% (95% CI, -86.0% to -75.0%) lower than Medicaid enrollment in 2014 and 88.6% (95% CI, -90.8% to -86.0%) lower in 2015 among those close to the 138% FPL eligibility threshold. The drop-off in marketplace enrollment was largest among younger adults, aged 26 to 34 and 35 to 44 years: relative drop off -88.7% (95% CI, -93.3% to -80.8%) and -87.8% (95% CI, -90.8% to -83.9%) in 2014, and relative drop off -91.9% (95% CI, -94.5% to -87.9%) and -93.0% (95% CI, -94.5% to -91.1%) in 2015, respectively.Conclusions and relevanceIn this cross-sectional study using a regression-discontinuity analysis, meaningful gaps in insurance enrollment may have existed for those with incomes just above the eligibility threshold for Medicaid expansion, especially among younger adults. Policies expanding Medicaid income eligibility or zero-dollar premium marketplace plans are likely to be more effective at inducing enrollment than subsidized private plans with premium requirements.

Project description:BackgroundSeveral states expanded Medicaid under the Affordable Care Act using Section 1115 waivers to implement healthy behavior incentive (HBI) programs, but the impact of this type of expansion relative to traditional expansion is not well understood.ObjectiveTo examine whether Medicaid expansion with healthy behavior incentive programs and traditional Medicaid expansion were associated with differential changes in coverage, access, and self-rated health outcomes among low-income adults.DesignDifference-in-differences analysis of American Community Survey and Behavioral Risk Factor Surveillance System data from 2011 to 2017.ParticipantsLow-income adults ages 19-64 in the Midwest Census region (American Community Survey, n = 665,653; Behavioral Risk Factor Surveillance System, n = 71,959).InterventionsExposure to either HBI waiver or traditional Medicaid expansion in the state of residence.Main measuresCoverage: Medicaid, private, or any health insurance coverage; access: routine checkup, personal doctor, delaying care due to cost; health: cancer screening, preventive care, healthy behaviors, self-reported health.Key resultsHealthy behavior incentive (HBI) and traditional expansion (TE) states experienced reductions in uninsurance (- 5.6 [- 7.5, - 3.7] and - 6.2 [- 8.1, - 4.4] percentage points, respectively) and gains in Medicaid (HBI, + 7.6 [2.4, 12.8]; TE, + 9.7 [5.9, 13.4] percentage points) relative to non-expansion states. Both expansion types were associated with increases in rates of having a personal doctor (HBI, + 3.8 [2.0, 5.6]; TE, + 5.9 [2.2, 9.6] percentage points) and mammography (HBI, + 5.6 [0.6, 10.6]; TE, + 7.3 [0.7, 13.9] percentage points). Meanwhile, checkups increased more in HBI than in TE states (p < 0.01), but no other changes in health care services differed between expansion types.ConclusionsMedicaid expansion was associated with improvements in coverage and access to care with few differences between expansion types.

Dataset Information

Medicaid Coverage Expansions and Cigarette Smoking Cessation Among Low-income Adults.

Publications

Medicaid Coverage Expansions and Cigarette Smoking Cessation Among Low-income Adults.

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