Tobacco Cessation in Affordable Care Act Medicaid Expansion States versus Non-Expansion States.

Abstract

INTRODUCTION\nCommunity 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.\n\n\nMETHODS\nUsing electronic health record (EHR) data from 219 CHCs in 10 states that expanded Medicaid as of 1/1/2014, we identified patients aged 19-64 with tobacco use status documented in the EHR within six months prior to ACA Medicaid expansion and ≥1 visit with tobacco use status assessed within 24 months post-expansion (1/1/2014-12/31/2015). We propensity score matched these patients to tobacco users from 108 CHCs in 6 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.\n\n\nRESULTS\nPatients in expansion states had increased adjusted odds of quitting (aOR=1.35, 95% 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.\n\n\nCONCLUSIONS\nIncreased access to insurance via the ACA Medicaid expansion likely led to increased quit rates within this vulnerable population.\n\n\nIMPLICATIONS\nCommunity health centers (CHCs) care for vulnerable patients at higher risk of tobacco use than the general population. Medicaid expansion via the Affordable Care Act (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.