The Affordable Care Act (ACA) coverage expansions to childless adults, through Medicaid and Health Insurance Exchanges, could have broad effects on public health. A recent study gives us one good example of that by showing that pregnant women in Medicaid with tobacco cessation coverage were less likely to smoke during pregnancy, but only if they had such coverage before becoming pregnant, as childless adults. Since the ACA’s Essential Health Benefits package includes tobacco cessation services, the law could help many more future mothers to quit smoking during or (ideally) before pregnancy.

Childless Adults Not Usually Covered Under Pre-ACA Medicaid:

Before the Affordable Care Act (ACA), Medicaid was intended to serve specific subsets of the low-income population, primarily children, parents, disabled adults, and pregnant women. But many states had expanded Medicaid beyond the federal government’s minimum Medicaid eligibility requirements.

All but four states allow children whose parents earn more than 200 percent of federal poverty level to be eligible for the Children’s Health Insurance Program (CHIP). 23 states have expanded Medicaid eligibility to pregnant women with incomes of 185 percent of federal poverty level or more (the federal minimum eligibility is 133% of FPL).

Childless adults, however, have largely been left out of Medicaid. Only nine states offer full Medicaid benefits to low-income childless adults. As a result, childless adults will be one of the largest groups among those newly eligible for Medicaid starting in 2014, when the health reform law Medicaid expansion takes effect and allows anyone with income less than 138 percent of federal poverty level to enroll.

Study Finds Smoking Cessation Benefits in Medicaid Reduce Smoking During Pregnancy:

Expanding health coverage to millions of adults through Medicaid and the Health Insurance Exchanges (HIX) could have a significant effect on public health. One recent study in the Medicare and Medicaid Research Review gives a small example of the potential benefits of covering childless adults.

The study looked at a sample of more than 175,000 pregnant women in Medicaid over 12 years and in 34 states, to determine whether expectant mothers covered in Medicaid were less likely to smoke if the state Medicaid program covered smoking cessation services. Smoking during pregnancy is associated with preterm deliveries and low birth weights, both of which could increase health costs.

One in five pregnant women with Medicaid coverage smokes during the last three months of pregnancy, compared to only 6 percent of pregnant women with private coverage who do so, note study authors E. Kathleen Adams and Sara Markowitz of Emory University, and Patricia M. Dietz and Van T. Tong of the Centers for Disease Control and Prevention (CDC). Since Medicaid insures a significant proportion of births across the country, lowering the rates of smoking during pregnancy could save money while improving public health.

Their findings were, in short:

  • Medicaid coverage of nicotine replacement therapies and medications is associated with 1.6 percentage point reduction in smoking before pregnancy among women with Medicaid relative to those without such benefits.
  • Adding counseling coverage to nicotine replacement therapies and medication coverage is associated with a 2.5 percentage point reduction in smoking before pregnancy.
  • Medicaid cessation coverage during pregnancy was associated with a small increase (<1 day) in infant gestation.

Most importantly, Medicaid smoking cessation coverage only had an effect for women enrolled in Medicaid before they were pregnant, when they were childless adults who would not have been covered in most states. The finding is significant because tobacco cessation coverage is one of the Essential Health Benefits (EHB) without co-pays for people who enroll in Qualified Health Plans (QHP) on the exchanges and in Medicaid. In the authors’ words:

“Expansions of Medicaid eligibility to include more women prior to pregnancy in participating states, and mandated coverage of some cessation services without co-pays under the Affordable Care Act (ACA) should reduce the number of women smoking before pregnancy.”

Musical Chairs of Coverage Under ACA:

Of course, the Supreme Court’s decision in NFIB v. Sebelius gave all states the option to expand Medicaid under the ACA. Fifteen states have already formally opted out, and three more states are likely to do the same, according to Sellers Dorsey. States choosing not to expand Medicaid under the ACA could do so in other ways, for example using a Medicaid waiver, as Texas has contemplated.

Meanwhile, many states will likely reduce optional Medicaid coverage for adults where Medicaid coverage overlaps with new federally subsidized coverage in Exchanges.  This would reduce state spending and streamline program eligibility.  Also, ACA is expected to cause some workers – about 8 million, according conservative estimates by the Congressional Budget Office (CBO) – to lose employer-sponsored health insurance.  Many of these folks will move to taxpayer funded coverage in Medicaid or Exchanges.

Some 26 states have chosen to not run their own Health Insurance Exchanges, but residents to those states will still have access to a federally run exchange.  In some other states, the Exchange will be jointly operated by CMS and the state.  Therefore, every individual eligible for new federally subsidized coverage will have an Exchange (called a Marketplace by CMS and some states) to use in applying for coverage and selecting a plan.