Date Published: February 16, 2017
Publisher: Public Library of Science
Author(s): Jennifer Kahende, Ann Malarcher, Lucinda England, Lei Zhang, Paul Mowery, Xin Xu, Varadan Sevilimedu, Italia Rolle, Takeru Abe.
To assess state coverage and utilization of Medicaid smoking cessation medication benefits among fee-for-service enrollees who smoked cigarettes.
We used the linked National Health Interview Survey (survey years 1995, 1997–2005) and the Medicaid Analytic eXtract files (1999–2008) to assess utilization of smoking cessation medication benefits among 5,982 cigarette smokers aged 18–64 years enrolled in Medicaid fee-for-service whose state Medicaid insurance covered at least one cessation medication. We excluded visits during pregnancy, and those covered by managed care or under dual enrollment (Medicaid and Medicare). Multivariate logistic regression was used to determine correlates of cessation medication benefit utilization among Medicaid fee-for-service enrollees, including measures of drug coverage (comprehensive cessation medication coverage, number of medications in state benefit, varenicline coverage), individual-level demographics at NHIS interview, age at Medicaid enrollment, and state-level cigarette excise taxes, statewide smoke-free laws, and per-capita tobacco control funding.
In 1999, the percent of smokers with ≥1 medication claims was 5.7% in the 30 states that covered at least one Food and Drug Administration (FDA)-approved cessation medication; this increased to 9.9% in 2008 in the 44 states that covered at least one FDA-approved medication (p<0.01). Cessation medication utilization was greater among older individuals (≥ 25 years), females, non-Hispanic whites, and those with higher educational attainment. Comprehensive coverage, the number of smoking cessation medications covered and varenicline coverage were all positively associated with utilization; cigarette excise tax and per-capita tobacco control funding were also positively associated with utilization. Utilization of medication benefits among fee-for-service Medicaid enrollees increased from 1999–2008 and varied by individual and state-level characteristics. Given that the Affordable Care Act bars state Medicaid programs from excluding any FDA-approved cessation medications from coverage as of January 2014, monitoring Medicaid cessation medication claims may be beneficial for informing efforts to increase utilization and maximize smoking cessation.
Cigarette smoking is the leading cause of premature disease and deaths in the U.S. accounting for approximately 480,000 deaths annually . Medicaid recipients are disproportionately affected by the burden of tobacco use: cigarette smoking prevalence among Medicaid enrollees is significantly higher than in the general adult population (30.1% vs.18.1%) . Smoking accounts for an estimated 15.2% of Medicaid program expenditures, or $40.1 billion annually .
The number of states that covered at least one drug increased from 30 in 1999 to 45 in 2008, and the number of states that offered comprehensive drug coverage increased from 13 in 1999 (≥5 drugs) to 24 in 2008 (≥7 drugs) (Table 1). During 2000–2008, at least 50% of states that covered one or more smoking cessation drugs had comprehensive coverage.
During 1999–2008, both the number of states that covered at least one FDA-approved smoking cessation medication and the number of states with comprehensive cessation medication coverage increased. In addition, among smokers from states whose Medicaid program covered at least one medication and who were enrolled in Medicaid fee-for-service, the percentage with one or more cessation medication claims also increased from 5.7% to 9.9% during the same time period. Comprehensive coverage, the number of cessation medications covered, and varenicline coverage, which was approved by the FDA in 2006, were all positively associated with having a medication claim. Cessation medication claims also varied by the enrollee’s demographic characteristics and the state’s excise tax and per-capita tobacco control funding. While it is encouraging that utilization of cessation medication is increasing among Medicaid enrollees who smoke, use remains low. The 9.9% utilization in our study is similar to the 10.0% utilization found in 2013 by Ku et al.  using 2010–2013 Medicaid state aggregate prescription drug rebate data that included both fee-for-service and managed care prescriptions. Well-funded comprehensive state tobacco control programs which include anti-tobacco mass media campaigns, increased cigarette excise taxes, and barrier-free access to cessation treatments are needed to further increase cessation among the smoking population in general including Medicaid enrollees [4,25,26].