Evidence Suggests That The ACA's Tobacco Surcharges Reduced Insurance Take-Up And Did Not Increase Smoking Cessation

Health Aff (Millwood). 2016 Jul 1;35(7):1176-83. doi: 10.1377/hlthaff.2015.1540.


To account for tobacco users' excess health care costs and encourage cessation, the Affordable Care Act (ACA) allowed insurers to impose a surcharge on tobacco users' premiums for plans offered on the health insurance exchanges, or Marketplaces. Low-income tax credits for Marketplace coverage were based on premiums for non-tobacco users, which means that these credits did not offset any surcharge costs. Thus, this policy greatly increased out-of-pocket premiums for many tobacco users. Using data for 2011-14 from the Behavioral Risk Factor Surveillance System, we examined the effect of tobacco surcharges on insurance status and smoking cessation in the first year of the exchanges' implementation, among adults most likely to purchase insurance from them. Relative to smokers who faced no surcharges, smokers facing medium or high surcharges had significantly reduced coverage (reductions of 4.3 percentage points and 11.6 percentage points, respectively), but no significant differences in smoking cessation. In contrast, those facing low surcharges showed significantly less smoking cessation. Taken together, these findings suggest that tobacco surcharges conflicted with a major goal of the ACA-increased financial protection-without increasing smoking cessation. States should consider these potential effects when deciding whether to limit surcharges to less than the federal maximum.

Keywords: Health Reform; Insurance Coverage < Insurance; Tobacco/Smoking.

MeSH terms

  • Adult
  • Confidence Intervals
  • Databases, Factual
  • Female
  • Health Care Costs / trends*
  • Humans
  • Insurance Coverage / economics*
  • Likelihood Functions
  • Male
  • Middle Aged
  • Patient Protection and Affordable Care Act / economics*
  • Patient Protection and Affordable Care Act / statistics & numerical data
  • Predictive Value of Tests
  • Retrospective Studies
  • Smoking / adverse effects
  • Smoking / epidemiology*
  • Smoking Cessation / economics*
  • Smoking Cessation / statistics & numerical data*
  • United States
  • Young Adult