2 tables omitted
Tobacco use is the leading preventable cause of death in the United
States.1 One of the national health objectives for 2010 is to increase
insurance coverage of evidence-based treatment for nicotine dependence (i.e.,
total coverage of behavioral therapies and Food and Drug Administration [FDA]–approved
pharmacotherapies) in Medicaid programs from 36 states to all states and the
District of Columbia (DC) (objective 27.8).2 To increase both the
use of treatment by smokers attempting to quit and the number of smokers who
quit successfully,3,4 the Guide to Community
Preventive Services5 recommends reducing the "out-of-pocket"
cost of effective tobacco-dependence treatments (i.e., individual, group,
and telephone counseling, and FDA–approved pharmacotherapies) for smokers.
The 2000 Public Health Service (PHS) Clinical Practice Guideline supports expanded insurance coverage for tobacco-dependence treatments.6 In 2000, approximately 32 million low-income persons in the United
States received their health insurance coverage through the federal-state
Medicaid program7; 11.5 million (36%) of these persons smoked (CDC,
unpublished data, 2000). The amount and type of coverage for tobacco-dependence
treatment offered by Medicaid has been reported for 1998 and 2000 from state
surveys conducted by the Center for Health and Public Policy Studies (CHPPS)
at the University of California, Berkeley.8 All states and DC were
re-surveyed in 2001 about amount and type of coverage, and level of coverage
since 1994. This report summarizes the results of the survey, which indicate
that the number of Medicaid programs providing some coverage for tobacco-dependence
counseling or medication increased from 34 in 2000 to 36 in 2001, but only
one state offered coverage for all the counseling and pharmacotherapy treatments
recommended by the 2000 PHS guideline. If the 2010 national health objective
is to be achieved, Medicaid coverage for treatment of tobacco dependence should
be increased dramatically.
In 2001, state Medicaid program directors were asked to identify staff
members who were most knowledgeable about tobacco-dependence treatment coverage
and programs; a survey was faxed to the identified staff member in each state.
Additional follow-up was conducted through telephone, e-mail, and fax; the
response rate was 100%. The survey included 24 questions about coverage of
tobacco-dependence treatments, the year coverage was first offered, treatments
offered specifically to pregnant women, awareness and use of the 2000 PHS
guideline,6 any program requirements related to patient co-payments
for or provider coverage of tobacco-dependence treatments, and whether Medicaid
recipients were notified of the availability of covered tobacco-dependence
treatment. So that survey responses could be validated, all Medicaid programs
were asked to submit a written copy of their coverage policies for tobacco-dependence
treatments or other related documentation. Of 36 areas with programs that
reported offering coverage in 2001, a total of 24 (67%) provided supporting
documentation, six (17%) reported that tobacco-dependence treatments were
covered under general benefits, and six (17%) did not submit any documentation.
In 2001, a total of 36 (71%) areas reported offering coverage for at
least one form of tobacco-dependence treatment, compared with 34 areas in
20008; however, coverage status reported previously in 2000 was
revised on the basis of additional information obtained in the 2001 survey
about the source of financing and the purpose for which a treatment was covered.
In 2000, Massachusetts reported coverage for tobacco-dependence treatments;
in the 2001 survey, the state clarified that counseling services were covered
by the Massachusetts Department of Public Health rather than by the Medicaid
program and that Wellbutrin® was covered only as an antidepressant and
not for treatment of tobacco dependence. In the 2000 survey, Utah reported
not having any covered treatment; however, in 2001, the state reported having
offered coverage for pregnant women since 2000. Of the 36 areas that offered
any coverage in 2001, all but one covered pharmacotherapy treatments, including
Zyban® (35 areas), Wellbutrin® (33), buproprion sustained release
(33), nicotine nasal spray (26), nicotine inhaler (26), nicotine patch (25),
and nicotine gum (24). Among the 35 areas with Medicaid programs covering
any pharmacotherapy treatments, 16 (46%) required some form of patient cost
sharing (range: $0.50 to $3.00 per prescription).
In 2001, a total of 10 states offered some form of tobacco-cessation
counseling services. Utah restricted counseling services to pregnant women
only, and Rhode Island offered counseling services but did not provide coverage
for any drug treatments.
In 2001, Medicaid program staff in 28 (55%) states reported being aware
of the 2000 PHS guideline, compared with 20 in 2000 (CHPPS, unpublished data,
2000). A total of 16 (31%) states reported using the 1996 Agency for Health
Care Policy and Research guideline or the 2000 PHS guideline to design tobacco-dependence
treatment benefits or programs. Ten (20%) states required contracted providers
or health plans to implement the brief counseling protocol recommended by
the 2000 PHS guideline, six (11%) states required providers or health plans
to document tobacco-use status in patients' medical charts, and 12 (24%) states
supported tobacco-dependence treatment practices (e.g., by distributing materials
on available treatments or self-help kits or by giving providers feedback
on their performance in treating tobacco dependence). Twelve (33%) Medicaid
programs that provided coverage informed their recipients that tobacco-dependence
treatment benefits were available.
HA Halpin, PhD, J Ibrahim, PhD, Center for Health and Public Policy
Studies, School of Public Health, Univ of California, Berkeley. CT Orleans,
PhD, Robert Wood Johnson Foundation, Princeton, New Jersey. AC Rosenthal,
MPH, CG Husten, MD, T Pechacek, PhD, Office on Smoking and Health, CDC.
The number of Medicaid programs offering any form of tobacco-dependence
treatments increased from 2000 to 2001, but coverage for the 2000 PHS guideline–recommended
treatments remained low. In 2001, a total of 15 areas offered no coverage
for tobacco-dependence treatments, and only Oregon provided coverage for all
treatment options recommended by the 2000 PHS guideline.6 In addition,
some states that did offer coverage required patients to share the cost, which
has been proven to decrease use of treatment.9 Such co-payments
might be even more of a barrier for low-income populations. Because decreasing
the cost of effective treatments increases successful smoking cessation,5 cost barriers for low-income smokers should be reduced. In addition,
because only one third of states that offer benefits inform their beneficiaries
of these benefits, Medicaid smokers interested in quitting might not realize
they can obtain financial assistance for tobacco-dependence treatment.
The findings in this report are subject to at least three limitations.
First, for some states, data are self-reported, and among the 36 states with
Medicaid programs that reported offering coverage, six states did not provide
documentation of their policies. The absence of a written policy increases
the likelihood of reporting errors. Second, these results might differ from
other ratings of coverage because of interpretation of unwritten policies.
Finally, the data presented in this report are current as of December 2001
and do not reflect coverage decisions made after that date.
Because Medicaid recipients have approximately 50% greater smoking prevalence
than the overall U.S. adult population,8 they are disproportionately
affected by tobacco-related disease and disability. Substantial action to
improve coverage will be needed if the United States is to achieve the national
health objective for 2010 of reducing the prevalence of smoking to 12% among
adults (i.e., persons aged ≥18 years) (objective 27.1).2 To
help states implement evidence-based tobacco-dependence treatment and to improve
Medicaid service contracts, CDC is collaborating with George Washington University
in developing model purchasing specifications.10 These
specifications encourage state Medicaid contracts to require that health-care
providers and health plans adopt the brief counseling protocol and systems
components outlined in the 2000 PHS guideline. States also are encouraged
to use their contracts to track the number of Medicaid smokers and the number
of smokers who receive advice to quit, brief cessation counseling, and medication.
Finally, states are encouraged to cover all recommended pharmacotherapies
and counseling under Medicaid and to promote their use actively.
References: 10 available
State Medicaid Coverage for Tobacco-Dependence Treatments—United States, 1994-2001. JAMA. 2003;290(3):327-328. doi:10.1001/jama.290.3.327