Effect of Gaining Insurance Coverage on Smoking Cessation in Community Health Centers: A Cohort Study

Abstract

Background: Community health center (CHC) patients have high rates of smoking. Insurance coverage for smoking cessation assistance, such as that mandated by the Affordable Care Act, may aid in smoking cessation in this vulnerable population.

Objective: We aimed to determine if uninsured CHC patients who gain Medicaid coverage experience greater primary care utilization, receive more cessation medication orders, and achieve higher quit rates, compared to continuously uninsured smokers.

Design: Longitudinal observational cohort study using electronic health record data from a network of Oregon CHCs linked to Oregon Medicaid enrollment data.

Patients: Cohort of patients who smoke and who gained Medicaid coverage in 2008-2011 after ≥ 6 months of being uninsured and with ≥ 1 smoking assessment in the 24-month follow-up period from the baseline smoking status date. This group was propensity score matched to a cohort of continuously uninsured CHC patients who smoke (n = 4140 matched pairs; 8280 patients).

Intervention: Gaining Medicaid after being uninsured for ≥ 6 months.

Main measures: 'Quit' smoking status (baseline smoking status was 'current every day' or 'some day' and status change to 'former smoker' at a subsequent visit), smoking cessation medication order, and ≥ 6 documented visits (yes/no variables) at ≥ 1 smoking status assessment within the 24-month follow-up period.

Key results: The newly insured had 40 % increased odds of quitting smoking (aOR = 1.40, 95 % CI:1.24, 1.58), nearly triple the odds of having a medication ordered (aOR = 2.94, 95 % CI:2.61, 3.32), and over twice the odds of having ≥ 6 follow-up visits (aOR = 2.12, 95 % CI:1.94, 2.32) compared to their uninsured counterparts.

Conclusions: Newly insured patients had increased odds of quit smoking status over 24 months of follow-up than those who remained uninsured. Providing insurance coverage to vulnerable populations may have a significant impact on smoking cessation.

Keywords: Medicaid; community health centers; insurance coverage; smoking cessation.

Conflict of interest statement

Compliance with Ethical Standards Conflicts of Interest Stephen P. Fortmann has received prior funding from Astra-Zeneca as a co-investigator on an observational study of hypertriglyceridemia in patients with diabetes. All other authors declare that they do not have a conflict of interest.

Figures

Figure 1

Odds ratios for outcomes related to smoking cessation (patients who gained Medicaid compared to continuously uninsured). Footnote: LCL = lower control limit; UCL = upper control limit. All odds ratios from generalized estimating equation models with clustering effect of propensity score-matched pair, adjusted for primary health center and having a usual source of care. Odds ratios by medication ordered from patient type*medication order interaction (interaction term was not significant in the model, p = 0.72). Odds ratios by number of visits from patient type*visit strata interaction (interaction term was not significant in the model, p = 0.48).