The Campaign for Tobacco-Free Kids released a study this week confirming that gaps exist in tobacco cessation coverage provided by many insurance companies and many consumers lack full access to tobacco cessation therapies as required by the Affordable Care Act (ACA).
The ACA requires that insurers and employers cover all A and B grade preventive services recommended by the U.S. Preventive Services Task Force (USPSTF). The USPSTF recommends clinicians ask all adult patients about their tobacco use and provide behavioral counseling and pharmacotherapy to those that use tobacco. The USPSTF’s tobacco cessation recommendation received an A grade, indicating there is high certainty of a substantial benefit from delivering the service, and is therefore required to be covered with no cost-sharing.
Researchers at Georgetown University’s Health Policy Institute analyzed thirty-nine insurance contracts across six states for their compliance with the ACA. Significant variation was found in how tobacco cessation was covered in those contracts. The research found that:
• Tobacco cessation did not appear to be covered at all in some contracts.
• Other contracts contained conflicting provisions that made it difficult to determine tobacco cessation treatment was covered or the scope of the benefit.
• Some contracts were unclear on the terms of cost-sharing or were ambiguous about potential restrictions to accessing covered treatment.
• Many contracts did not cover pharmacotherapy (either prescription or over-the-counter).
• None of the 39 analyzed contracts (1) clearly stated that tobacco cessation treatment was covered, (2) provided coverage for individual, group, and phone counseling and FDA-approved cessation medication, (3) provided treatment by in-network providers with no-cost sharing, and (4) provided access to treatment with prerequisites (e.g., medical necessity or a health risk assessment).
• Only four (of 39) contracts covered individual, group, and phone counseling, and both prescription and over-the-counter medications.
In short, the report questions whether effective tobacco cessation services are actually available to consumers as required by the ACA. The confusing and ambiguous language contained in many insurance contracts makes it difficult for consumers to know what is covered, how to access treatment, and whether there is cost-sharing.
Insurance coverage of tobacco cessation treatment is crucial to reducing prevalence of tobacco use in the U.S. Evidence-based studies, such as The Return on Investment of a Medicaid Tobacco Cessation Program in Massachusetts (funded by Partnership for Prevention) and referenced in the Georgetown report, conclude that tobacco cessation services not only saves lives but are also cost effective. Every $1 invested in the Massachusetts Medicaid Tobacco Cessation Program led to average savings of $3.12 in cardiovascular-related hospitalization expenditures. Thus, a net return on investment of $2.12 was realized and on average these savings were recouped within slightly more than a year after the benefits were used.
To combat tobacco use in our nation we must uphold the ACA’s preventive services coverage requirements in a manner that is accessible and affordable to tobacco users. This will save lives and millions of dollars in tobacco-related health expenditures. In light of the increasing burden of healthcare on the U.S. economy, it would be irresponsible to do otherwise.