Capsule Commentary on Bailey et al., Effect of Gaining Insurance Coverage on Smoking Cessation in Community Health Centers: A Cohort Study

Abstract

W ith passage of the Affordable Care Act (ACA) in 2010, more than 8 million Americans obtained insurance coverage by 2014, over half via Medicaid. 1 Proponents of the ACA argued it would achieve major public health milestones by tying insured patient populations to evidence-based public health initiatives. As tobacco smoking continues to be the leading cause of preventable death in the US, Bailey and colleagues focused on the effects of obtaining Medicaid insurance coverage in a cohort of previously uninsured smokers. They found a three-fold increase in prescription of smoking cessation aids and an impressive 40 % decrease in smoking over 24 months of follow-up (though the absolute reduction was only 3 %). They conclude that obtaining insurance leads to increased tobacco cessation. 2 Although not the focus of their research, their study showed that primary care providers prescribed tobacco cessation medications to only a small proportion of smokers, less than 27% of insured and 12 % of uninsured patients. Primary care providers have consistently under performed in providing tobacco cessation services despite evidence-based guidelines. 3 As Bailey and colleagues point out, this higher rate of prescriptions does not fully explain their results, particularly since the trend toward higher quit rates occurred even among patients in which no cessation medication was ordered. 2 One possibility is referral to smoking cessation counseling, a variable not captured in this study. Another is that obtaining insurance may be a marker of desire for healthier living. Another possibility is that the results are spurious, given the relatively small difference between the two groups and that the results are based on propensity score matching. Several previous studies have shown benefit from obtaining health insurance including reducing mortality 4 and increasing use of preventive services. 5 This study suggests that another potential benefit for gaining insurance is a reduction in smoking. If this is true, the potential cost savings for universal coverage could be huge, given the long-term consequences of smoking on health.