In an ideal world, promoting prevention should involve three logical and easy steps: 1) identify a high-risk population, 2) encourage effective preventive services to lower risk in that population, and 3) document high uptake of those services with subsequent improvements in health. But the real world of prevention is never this easy. As a prominent example, efforts to broadly implement tobacco cessation services for Medicaid populations, as documented in a January Health Affairs article by Leighton Ku et al, demonstrate how difficult it all can be.
To prevent death and suffering from tobacco, focusing the first two steps on Medicaid seems reasonable and clear. Regarding the first step, smoking prevalence among Medicaid beneficiaries is more than twice that for adults with private health insurance (29.1 percent vs 12.9 percent 2014), as low-income people are at disproportionately high risk.
This disparity is not new. In fact, in the late 1990s, this disproportionate burden (and its related exorbitant expenses) motivated state Attorneys General collectively to sue the largest tobacco companies to recoup Medicaid-related health costs. The lawsuits culminated in the historic Master Settlement Agreement (1998), where, among other provisions, the industry agreed to limit certain marketing practices and pay 46 states $206 billon over the next 25 years. Unfortunately, however, little of that money has since been dedicated to fund disease prevention and public health. For this and other reasons, the problem of tobacco dependence persists unabated for the Medicaid population.
For the second step, focusing effective tobacco prevention and cessation services on Medicaid beneficiaries makes great sense as a national public health strategy. As the former US Assistant Secretary for Health, I had the privilege of overseeing, and in 2010 unveiling (with Secretary Kathleen Sebelius) Ending the Tobacco Epidemic, the first ever tobacco control strategic action plan for the US Department of Health and Human Services (HHS).
In that strategy, HHS prioritized the importance of access to proven counseling and Food and Druga Administration (FDA)-approved pharmacotherapy for smokers, as summarized in the evidence-based US Public Health Service Clinical Practice Guideline: Treating Tobacco Use and Dependence. As the Affordable Care Act (ACA) requires that all state Medicaid programs cover some cessation services for enrollees, the potential for improving tobacco-related prevention seemed high.
The Challenge Of Demonstrating Uptake
It is the third step of prevention—demonstrating high uptake of preventive services and documenting improved health—that is always the toughest. In their study, Ku et al find that as a nation, we are still far from the goal of reaching high levels of critical smoking cessation services for Medicaid enrollees. Their analysis estimates that in 2013 only about one in 10 current smokers in Medicaid nationwide received cessation medications.
Many factors appear to contribute to this suboptimal outcome. While most smokers want to quit, they may be largely unaware that Medicaid-covered tobacco cessation services exist. Many providers, similarly unaware, do not offer such services to their patients. Issues of prior authorization and cost sharing present further barriers to accessing services. And the uneven expansion of Medicaid coverage across the country complicates the situation further.
Of note, some cessation services may be available with no cost sharing for new enrollees covered by Medicaid expansion but not for those covered by traditional pre-expansion Medicaid. This discrepancy can exacerbate the already striking state-by-state variation of use of tobacco-related preventive services.
The era of health reform offers potentially powerful ways to redouble tobacco prevention efforts for Medicaid beneficiaries. In The New England Journal of Medicine, Tim McAfee et al recently reviewed the opportunities created by the Affordable Care Act to help smokers quit. They note that states are prohibited from excluding FDA-approved cessation medications from traditional, pre-expansion Medicaid coverage. Another provision requires traditional state Medicaid programs to include a comprehensive cessation benefit for pregnant women smokers. People receiving insurance coverage from other public or private plans also enjoy new opportunities for counseling and cessation services without cost sharing.
Meanwhile, some states have demonstrated that aggressive tobacco prevention services can lead to noteworthy results. For example, in Massachusetts, the 2006 Medicaid tobacco cessation benefit, achieved as part of that state’s health reform efforts, received great attention through extensive outreach and education to patients and providers.
As a result, over a three year period, 37 percent of smokers covered by Massachusetts Medicaid used the benefit. The overall smoking rate fell from 38 percent to 28 percent. The state also witnessed major drops in hospitalization for myocardial infarction as well as a return on investment of over $3 in medical savings for every dollar spent. Such progress in other states could ultimately benefit the nation as a whole.
In addition to promoting effective cessation services today, we also need even better strategies for the future. As one example of potential interventions on the horizon, Eric Donny et al randomized over 800 adult smokers to use (over six weeks) either standard cigarettes or a variety of investigational cigarettes with reduced nicotine content. Overall, those smoking very low nicotine product not only smoked fewer cigarettes but were also twice as likely to attempt to quit smoking than those in the former group. Future confirmation of these landmark results is needed. But if confirmed, such analyses could represent a novel avenue for exploring future national tobacco prevention policy.
We understand how, theoretically, the three basic steps of prevention should be realized. Now we need to make it happen. With heightened commitment to implementation and research, we can fill the gaps to improve smoking cessation for Medicaid enrollees. Doing so could serve as a model for prevention efforts in high- cost populations in the future.