Evaluating Community-Based Health Improvement Programs

Increasingly, public and private resources are being dedicated to community-based health improvement programs. But evaluations of these programs typically rely on data about process and a pre-post study design without a comparison community. To better determine the association between the implementation of community-based health improvement programs and county-level health outcomes, we used publicly available data for the period 2002-06 to create a propensity-weighted set of controls for conducting multiple regression analyses. We found that the implementation of community-based health improvement programs was associated with a decrease of less than 0.15 percent in the rate of obesity, an even smaller decrease in the proportion of people reporting being in poor or fair health, and a smaller increase in the rate of smoking. None of these changes was significant. Additionally, program counties tended to have younger residents and higher rates of poverty and unemployment than nonprogram counties. These differences could be driving forces behind program implementation. To better evaluate health improvement programs, funders should provide guidance and expertise in measurement, data collection, and analytic strategies at the beginning of program implementation.

Nearly Half Of Small Employers Using Tobacco Surcharges Do Not Provide Tobacco Cessation Wellness Programs

The Affordable Care Act (ACA) allowed employer plans in the small-group marketplace to charge tobacco users up to 50 percent more for premiums-known as tobacco surcharges-but only if the employer offered a tobacco cessation program and the employee in question failed to participate in it. Using 2016 survey data collected by the Henry J. Kaiser Family Foundation and Health Research and Educational Trust on 278 employers eligible for Small Business Health Options Program, we examined the prevalence of tobacco surcharges and tobacco cessation programs in the small-group market under this policy and found that 16.2 percent of small employers used tobacco surcharges. Overall, 47 percent of employers used tobacco surcharges but failed to offer tobacco cessation counseling. Wellness program prevalence was lower in states that allowed tobacco surcharges, and 10.8 percent of employers in these states were noncompliant with the ACA by charging tobacco users higher premiums without offering cessation programs. Efforts should be undertaken to improve the monitoring and enforcement of ACA tobacco rating rules.

Strategies for the Prevention of Coronary Artery Disease Complications: Can We Do Better?

Billions of dollars have been spent over the past 25 years on developing new therapies for the prevention/treatment of adverse cardiac events related to atherosclerotic cardiovascular disease. Although some therapies have been lifesaving, several mega-randomized studies have shown only a <2% absolute reduction in adverse events with a large residual event rate. Is all this money well spent? Atherosclerosis develops decades before an adverse event, and the trials previously alluded to have nearly always been applied to secondary prevention, decades after disease initiation. Will earlier intervention result in a lower incidence of events? Individuals with an absence of the usual cardiac risk factors have a lifelong low incidence of events. Early initiation of strategies against the common cardiovascular risk factors in primary or primordial prevention will lower the incidence of adverse events, although many groups have not been well studied, including individuals younger than 40 years of age. New strategies are required to realize a radical reduction in events, and this article proposes new methods of prevention/treatment for coronary artery disease complications.

Medicaid Tobacco Cessation: Big Gaps Remain In Efforts To Get Smokers To Quit

Medicaid enrollees are about twice as likely as the general US population to smoke tobacco: 32 percent of people in the program identify themselves as smokers. This article provides the first data about the effectiveness of state Medicaid programs in promoting smoking cessation. Our analysis of Medicaid enrollees' use of cessation medications found that about 10 percent of current smokers received cessation medications in 2013. Every state Medicaid program covers cessation benefits, but the use of these medications varies widely, with the rate in Minnesota being thirty times higher than that in Texas. Most states could increase their efforts to help smokers quit, working with public health agencies, managed care plans, and others. In 2013 Medicaid spent $103 million on cessation medications-less than 0.25 percent of the estimated cost to Medicaid of smoking-related diseases. Additionally, states that have not expanded Medicaid eligibility in the wake of the Affordable Care Act have higher smoking prevalence and lower utilization rates of cessation medication, compared to expansion states. Given these factors, nonexpansion states will have a greater public health burden related to smoking. Medicaid and public health agencies should work together to make smoking cessation a priority for Medicaid beneficiaries.

Framing Progress In Global Tobacco Control To Inform Action On Noncommunicable Diseases

Much has been learned about the tobacco epidemic, including its consequences, effective measures to control it, and the actors involved. This article identifies lessons learned that are applicable to the other principal external causes of noncommunicable diseases: alcohol abuse, poor nutrition, and physical inactivity. Among these lessons are the development of evidence-based strategies such as proven cessation methods, tax increases, and smoke-free policies; the role of multinational corporations in maintaining markets and undermining control measures; and the need for strategies that reach across the life course and that begin with individuals and extend to higher levels of societal organization. Differences are also clear. Tobacco products are relatively homogeneous and have no direct benefit to consumers, whereas food and alcohol consumed in moderation are not inherently dangerous. Some tobacco-related diseases have the singular predominant cause of smoking, while many noncommunicable diseases have multiple interlocking causes such as poor diet, excess alcohol consumption, insufficient physical activity, and smoking, along with genetics. Thus, the tobacco control model of comprehensive multilevel strategies is applicable to the control of noncommunicable diseases, but the focus must be on multiple risk factors.

Medicaid expansion in opt-out states would produce consumer savings and less financial burden than exchange coverage

In the twenty-three states that have decided against expanding Medicaid under the Affordable Care Act, uninsured adults who would have been eligible for Medicaid and have incomes at or above the federal poverty guidelines are generally eligible for Marketplace (insurance exchange) premium tax credits and plans with generous benefits. This study compared estimated out-of-pocket spending for care and premiums, as well as the financial burdens they impose, for the families of these adults under two simulation scenarios: obtaining coverage through a silver plan with subsidized cost sharing and enrolling in expanded Medicaid. Compared with Marketplace coverage, Medicaid would more than halve average annual out-of-pocket spending ($938 versus $1,948), while dramatically reducing the percentage of adults in families with out-of-pocket expenses exceeding 10 percent or 20 percent of income (6.0 percent versus 17.1 percent and 0.9 percent versus 3.7 percent, respectively). Larger reductions would be seen for families with smokers, who under Medicaid would no longer be subject to Marketplace tobacco user surcharges. Medicaid expansion may offer a greater opportunity than access to Marketplace insurance to promote the financial well-being of previously uninsured low-income adults.

Most exchange plans charge lower tobacco surcharges than allowed, but many tobacco users lack affordable coverage

Beginning in 2014, federal guidelines for health plans sold to people in the individual market allow insurers to charge tobacco users up to 50 percent more for premiums, compared to nonusers. We examined variations in tobacco surcharges for plans offered through the state and federal health insurance exchanges, or Marketplaces. The plan with the median surcharge had only 10 percent higher premiums for tobacco users compared to nonusers, and nine in ten plans charged a lower surcharge than allowed. Even with such lower-than-allowed surcharges, tobacco users lacked affordable coverage-defined as access to at least one plan with premiums of less than 8 percent of income after subsidies-in more states than did nonusers. Higher premiums could encourage tobacco users to opt out of coverage. Our results also suggest that the variation in tobacco surcharges may result in the sorting of tobacco users and nonusers into different plans.

Evidence Suggests That The ACA's Tobacco Surcharges Reduced Insurance Take-Up And Did Not Increase Smoking Cessation

To account for tobacco users' excess health care costs and encourage cessation, the Affordable Care Act (ACA) allowed insurers to impose a surcharge on tobacco users' premiums for plans offered on the health insurance exchanges, or Marketplaces. Low-income tax credits for Marketplace coverage were based on premiums for non-tobacco users, which means that these credits did not offset any surcharge costs. Thus, this policy greatly increased out-of-pocket premiums for many tobacco users. Using data for 2011-14 from the Behavioral Risk Factor Surveillance System, we examined the effect of tobacco surcharges on insurance status and smoking cessation in the first year of the exchanges' implementation, among adults most likely to purchase insurance from them. Relative to smokers who faced no surcharges, smokers facing medium or high surcharges had significantly reduced coverage (reductions of 4.3 percentage points and 11.6 percentage points, respectively), but no significant differences in smoking cessation. In contrast, those facing low surcharges showed significantly less smoking cessation. Taken together, these findings suggest that tobacco surcharges conflicted with a major goal of the ACA-increased financial protection-without increasing smoking cessation. States should consider these potential effects when deciding whether to limit surcharges to less than the federal maximum.

More americans living longer with cardiovascular disease will increase costs while lowering quality of life

In the past several decades, some risk factors for cardiovascular disease have improved, while others have worsened. For example, smoking rates have dropped and treatment rates for cardiovascular disease have increased-factors that have made the disease less fatal. At the same time, Americans' average body mass index and incidence of diabetes have increased as the population continues to live longer-factors that have made cardiovascular disease more prevalent. To assess the aggregate impact of these opposing trends, we used the nine National Health and Nutrition Examination Survey waves from 1973 to 2010 to forecast total cardiovascular disease risk and prevalence from 2015 to 2030. We found that continued improvements in cardiovascular disease treatment and declining smoking rates will not outweigh the influence of increasing population age and obesity on cardiovascular disease risk. Given an aging population, an obesity epidemic, and declining mortality from the disease, the United States should expect to see a sharp rise in the health care costs, disability, and reductions in quality of life associated with increased prevalence of cardiovascular disease. Policies that target the treatment of high blood pressure and cholesterol and the reduction of obesity will be necessary to curb the imminent spike in cardiovascular disease prevalence.

Medicaid enrollment policy increased smoking cessation among pregnant women but had no impact on birth outcomes

Cigarette smoking during pregnancy is an important cause of poor maternal and infant health outcomes in the population eligible for Medicaid. These outcomes may be avoided or attenuated by timely, high-quality prenatal care. Using data from the Centers for Disease Control and Prevention's Pregnancy Risk Assessment Monitoring System for the period 2004-10, we examined the effects of two optional state Medicaid enrollment policies on smoking cessation, preterm birth, and having an infant who was small for gestational age. We used a natural experiment to compare outcomes before and after nineteen states adopted either of the two policies. The first policy, presumptive eligibility, permits women to receive prenatal care while their Medicaid application is pending. Its adoption led to a 7.7-percentage-point increase in smoking cessation but did not reduce adverse birth outcomes. The second policy, the unborn-child option, permits states to provide coverage to pregnant women who cannot document their citizenship or residency. Its adoption was not significantly associated with any of the three outcomes. The presumptive-eligibility enrollment policy will continue to be an important tool for promoting timely prenatal care and smoking cessation.