Medicaid Coverage for Quitting Smoking, State by State, 2008–2018

Adults on Medicaid smoke at about twice the rate of adults with private insurance — 23.9% against 10.5% — which puts them at higher risk of smoking-related disease and death. Medicaid spends about $39 billion a year treating those diseases. Individual, group and telephone counseling help people quit, as do seven medications approved by the Food and Drug Administration (FDA): five forms of nicotine replacement (patch, gum, lozenge, nasal spray and inhaler) plus bupropion and varenicline. Coverage that includes all of them, has no hurdles and is widely publicized raises both their use and quit rates, and is cost-effective.

An MMWR report by the American Lung Association and CDC's Office on Smoking and Health traced how state Medicaid programs covered these treatments for traditional enrollees — people eligible under the program's original criteria, such as low-income pregnant women, children and people with disabilities, rather than through the income-only expansion — from December 31, 2008, to December 31, 2018.

What was counted

The report tracked nine treatments: individual counseling, group counseling and the seven FDA-approved medications. Telephone counseling, free to every caller to state quitlines in all 50 states and the District of Columbia through 1-800-QUIT-NOW, was not included. A state covering all nine was counted as having comprehensive coverage.

It also tracked seven barriers that make covered treatments harder to get: copayments, prior authorization, required counseling before medication, stepped care therapy, limits on how long treatment lasts, a yearly cap on covered quit attempts, and a lifetime cap. A barrier on even one treatment counted.

The Lung Association gathered the details from Medicaid and managed-care plan websites and handbooks, policy manuals, drug lists, state plan amendments, and laws and regulations, and checked them with state officials. In this report, "states" includes the District of Columbia.

Coverage grew

The 15 states with comprehensive coverage in 2018 were California, Colorado, Connecticut, Indiana, Kansas, Kentucky, Maine, Massachusetts, Minnesota, Missouri, Ohio, Oregon, Rhode Island, South Carolina and Wisconsin. Eleven of them reached that level during the decade. Nebraska and Pennsylvania went the other way: both covered all nine treatments in 2008 but not in 2018, because of changes in their managed-care plans.

Barriers remained

Only Kentucky and Missouri had removed all seven barriers; 13 (87%) of the 15 comprehensive states still had barriers on some treatments. The most common barriers in 2018 were limits on treatment length (44 states, 86%), yearly caps on quit attempts (37 states, 72%) and prior authorization (35 states, 69%). States made considerable progress in dropping copayments over the decade; progress on the other barriers was mixed.

Why coverage changed

The authors credited the Affordable Care Act, passed in March 2010, with part of the gain. From October 2010 it required Medicaid to cover counseling and FDA-approved cessation medications for pregnant women with no cost-sharing. From January 2014 it barred states in the Medicaid drug rebate program — all of them by the end of 2018 — from excluding FDA-approved cessation medications, which likely helped raise the number of states covering all seven. Outside pregnancy, the law did not require traditional Medicaid to cover counseling or to remove barriers.

Still short of the goal

Coverage still fell short of the Healthy People 2020 objective of comprehensive cessation coverage in every state and DC. Counseling lagged furthest behind medication, although counseling and medication together work better than either alone; one study linked combined Medicaid coverage of both to an estimated 3.0-percentage-point average increase in past-year quitting.

Coverage also varied between a state's managed-care plans, in both treatments and barriers. The authors urged states to have every plan cover every proven treatment with few barriers, which would also spare enrollees and clinicians confusion — more pressing as states shift enrollees from fee-for-service into managed care.

About 6.7 million adult smokers say they are on Medicaid, around 20% of U.S. adult cigarette smokers. They want to quit and try to quit as often as privately insured smokers, but succeed less often, and are more likely to have chronic disease and severe psychological distress. Smoking-related disease took about 15% of Medicaid spending in 2006–2010.

The report had two limitations: officials' answers could not always be verified where documents were missing, outdated or contradictory, and managed-care coverage can change with little notice.

Sources

• DiGiulio A, Jump Z, Babb S, et al. "State Medicaid Coverage for Tobacco Cessation Treatments and Barriers to Accessing Treatments — United States, 2008–2018." MMWR 2020;69(6). The report's visual abstract is not reproduced.