Strategy 3.3 - Making Treatment More Affordable - Expanding Coverage

    • May 25, 2010

RWJF has espoused the belief that tobacco use should be treated like other chronic diseases. As such, health plans should cover treatments for tobacco dependence in the same way they do for other chronic illnesses. (Read more about the case for treating tobacco dependence as a chronic disease in this journal article.)

What Is Known About Insurance Coverage for Treatment Services

To expand the reach and impact of evidence-based cessation treatments, RWJF supported efforts to expand insurance coverage for treatment. This work included research documenting the health and economic effects of smoking, and the cost-effectiveness and population-level cessation effects of expanding coverage via government programs (i.e. Medicare, Medicaid and the Veterans Administration), health plans and HMOs, employers, unions, and other purchasers of health insurance coverage.

  • Covering cessation treatment is cost-effective. As documented by the RWJF-supported National Commission on Prevention Priorities, brief primary-care quit-smoking interventions are cost-saving. Similarly, studies funded under the Substance Abuse Policy Research Program (SAPRP) documented that "the costs of [tobacco-cessation treatment services] are low relative to the potential return on investment in the form of reduced smoking-related health care expenditures." (From SAPRP Knowledge Asset.)
  • Full health coverage would result in 100,000 lives saved. SAPRP-funded research using the "Sim-Smoke" simulation modeling program found that more than 100,000 fewer lives would be lost to smoking-related deaths cumulatively by 2020, if full coverage were available for existing smoking-cessation treatments. (See news release.)
  • Smokers with full coverage have higher quit rates. Researchers at the Group Health Cooperative of Puget Sound published an article in the New England Journal of Medicine that states that one and a half times as many smokers would quit per year under full coverage compared to a plan that covers treatment partially. (See Program Results.)
  • Cost of coverage is a barrier. Another RWJF-funded study by Helen Schauffler, Diane Barker and C. Tracy Orleans found that barriers to coverage and use of tobacco-dependence treatments include, among other things, the cost of coverage.

    Together the two studies mentioned above provided the evidence on which the Centers for Disease Control and Prevention Community Preventive Task Force based its recommendation for reducing smokers' out-of-pocket treatment costs as a means of boosting population quit rates.
  • Coverage is growing. In 1995, no state Medicaid programs provided coverage for tobacco-dependence treatments. As documented by RWJF-funded surveys, by 2005, 42 states provided Medicaid coverage for tobacco-cessation counseling and/or medication. In 2002, nearly all private insurance plans provided full coverage for at least one type of smoking-cessation intervention. Medicare added cessation counseling benefits in 2005, and the Veterans Administration expanded its coverage for counseling and medication in 2005. According to the American Lung Association, in 2008, 43 states provided full coverage for at least one form of evidence-based cessation treatment. (See research summary, a journal article and news release, Campaign for Tobacco-Free Kids report and Lung Association research report.)

Key RWJF-Sponsored Initiatives: Research

  • Medicaid surveys. Between 1994 and 2008, RWJF supported regular surveys of states and their policies for covering tobacco-cessation treatments under Medicaid. (See the Center for Health and Public Policy Studies for a full list of the surveys.)
  • Managed care coverage surveys. Between 1996 and 2004, in partnership with the American Association of Health Plans, RWJF funded regular surveys of managed care plans to assess their coverage for tobacco-cessation medication and counseling. (See results from the 2002 survey and the 2003 survey.)
  • Need for coverage awareness efforts. Both the SAPRP and Addressing Tobacco in Managed Care (ATMC) programs funded studies of coverage expansions that document, among other things, that expanding benefits alone is not sufficient to increase their use in the absence of effective communications and promotions to enrollees and beneficiaries. (See a description of the SAPRP study and Program Results on ATMC.)
  • A related study of Medicaid beneficiaries and providers. This study, in two states, covered all approved cessation treatments found that only 36 percent of beneficiaries and 60 percent of their providers were aware of these benefits. The study's findings suggest that state Medicaid programs need to develop better communication with their enrollees who smoke to inform them about coverage for tobacco-dependence treatments and their effectiveness. (See journal article.) These findings led to recommendations by the Partnership for Prevention to both expand and promote available tobacco-dependence treatment benefits.

Key RWJF-Sponsored Initiatives: Action to Put Research Into Practice

  • Network of advocates. The Connecticut Peer Review Organization organized a network of advocates in the seven states who reached into their communities to enroll seniors in the Medicare Stop Smoking Program. (See Program Results.)
  • Group of experts. In 1996, the Pinney Group convened a working group of experts to examine the available evidence on insurance coverage for tobacco cessation and identify strategies for expanding coverage. (See Program Results.)

Key RWJF-Sponsored Initiatives: Advocacy & Communications Around What Works

Advocacy for Coverage Expansion

  • Three advocacy initiatives. Smokeless States, Tobacco Policy Change and the Center for Tobacco-Free Kids (CTFK) include benefit expansion as a core state and federal tobacco-control policy target. In December 2006, CTFK issued the first-ever model benefit for comprehensive cessation-treatment coverage.

Other Related Resources Funded by RWJF

  • A survey of employer coverage for preventive health services, including tobacco-cessation treatment. (See journal article.)
  • A research agenda for studies of the financial benefits of offering insurance coverage for smoking-cessation treatment in managed health care plans. (See Program Results.)
  • A study testing whether a mailing describing a health plan's new coverage for smoking-cessation medications increases benefit knowledge, utilization and quitting. (See journal article.)
  • A survey of Medicaid coverage for smoking-cessation treatment for pregnant women. (See journal article.)
  • A review of cessation coverage provided by states through Medicaid programs, state employee health plans and standards for private insurance. (See publication.)
  • A study of the effects of adding and removing full coverage for smoking-cessation treatments in primary care settings on treatment referrals and use. Krist et al, American Journal of Preventive Medicine, February 2010. (See journal article.)