Tobacco Cessation in Affordable Care Act Medicaid Expansion States Versus Non-expansion States

Abstract

Introduction: Community health centers (CHCs) care for vulnerable patients who use tobacco at higher than national rates. States that expanded Medicaid eligibility under the Affordable Care Act (ACA) provided insurance coverage to tobacco users not previously Medicaid-eligible, thereby potentially increasing their odds of receiving cessation assistance. We examined if tobacco users in Medicaid expansion states had increased quit rates, cessation medications ordered, and greater health care utilization compared to patients in non-expansion states.

Methods: Using electronic health record (EHR) data from 219 CHCs in 10 states that expanded Medicaid as of January 1, 2014, we identified patients aged 19-64 with tobacco use status documented in the EHR within 6 months prior to ACA Medicaid expansion and ≥1 visit with tobacco use status assessed within 24 months post-expansion (January 1, 2014 to December 31, 2015). We propensity score matched these patients to tobacco users from 108 CHCs in six non-expansion states (n = 27 670 matched pairs; 55 340 patients). Using a retrospective observational cohort study design, we compared odds of having a quit status, cessation medication ordered, and ≥6 visits within the post-expansion period among patients in expansion versus non-expansion states.

Results: Patients in expansion states had increased adjusted odds of quitting (adjusted odds ratio [aOR] = 1.35, 95% confidence interval [CI]: 1.28-1.43), having a medication ordered (aOR = 1.53, 95% CI: 1.44-1.62), and having ≥6 follow-up visits (aOR = 1.34, 95% CI: 1.28-1.41) compared to patients from non-expansion states.

Conclusions: Increased access to insurance via the ACA Medicaid expansion likely led to increased quit rates within this vulnerable population.

Implications: CHCs care for vulnerable patients at higher risk of tobacco use than the general population. Medicaid expansion via the ACA provided insurance coverage to a large number of tobacco users not previously Medicaid-eligible. We found that expanded insurance coverage was associated with increased cessation assistance and higher odds of tobacco cessation. Continued provision of insurance coverage could lead to increased quit rates among high-risk populations, resulting in improvements in population health outcomes and reduced total health care costs.

Figure 1.

Heterogeneity of ACA effects: adjusted odds ratios for quit status over 24 months comparing Medicaid expansion vs. non-expansion states (reference group) stratified by medication ordered, follow-up visits, percent of federal poverty level, and insurance status at baseline. Note: ACA= Affordable Care Act, LCL = lower confidence limit of the 95% confidence interval, UCL = upper confidence limit of the 95% confidence interval, CI = confidence interval. Odds ratios were estimated using GEE models accounting for clustering of patients at the clinic level and performed on propensity score matched sample. To assess heterogeneity of ACA effects on quit rates by clinic utilization, interactions between ACA expansion status and post-period utilization were added to the model. A similar approach was used for medication order status, federal poverty level at baseline and insurance at baseline. All models included a fixed-effect indicator for network site (OCHIN vs. HCN) to account for the higher-level clustering of CHC within network.