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Smokers Pay Extra, But Employee Health Plans Aren’t Helping Them Quit


A new study shows that ACA tobacco rating rules aren't enforced in employer plans.

Healthcare executives can help improve efforts to improve the monitoring and enforcement of ACA tobacco rating rules, a new study suggests.

According to the study, published in the March 2018 issue of Health Affairs, approximately half of small employers are using tobacco surcharges without providing wellness program access to quit using tobacco to their employees. The ACA allowed employer plans in the small-group marketplace to charge tobacco users up to 50% more for premiums.


Lead author Michael Pesko, a health economist at Georgia State University in Atlanta, and colleagues used a nationally-representative data source on employer health insurance offerings provided by the Kaiser Family Foundation. From this data, the researchers identified 278 employers eligible for Small Business Health Options Program, whether they used tobacco surcharges, and if so, whether they provided the ACA-required tobacco cessation wellness programs..

The study also found that 16% of small employers used tobacco surcharges in 2016, which affected 365,000 tobacco users nationally. “Wellness program prevalence was lower in states that allowed tobacco surcharges, and 10.8% of small employers in these states were noncompliant with the ACA by charging tobacco users higher premiums without offering cessation programs,” the authors wrote.

“Rates of noncompliance were higher for tobacco users in service and blue-collar industries, as well as tobacco users working for an employer with a larger percent of older workers,” says Pesko.

“Healthcare executives may have a financial incentive to ensure that the spirit of the ACA is being followed so that there is higher demand for workplace wellness programs,” Pesko says. “They may also have an intrinsic interest in ensuring that employees being charged higher premiums for health insurance because they smoke are also being provided with resources to quit smoking.”

The authors wrote that “Efforts to close loopholes in tobacco surcharge laws and improve outreach, monitoring, and enforcement should be undertaken to ensure that tobacco users have access to wellness programs to help them quit using tobacco. Further research should be conducted to determine how noncompliant plans are sold, whether through possible legal loopholes such as association health plans or grandfathered health plans or because of confusion about or failure to enforce ACA tobacco regulations.”

Meanwhile, Yale School of Public Health researchers found that the ACA’s tobacco surcharges reduced insurance take-up and did not increase smoking cessation. Their analysis, published in 2016 in Health Affairs, showed that increases in insurance coverage in 2014 were 12 percentage points lower among smokers facing the highest surcharges, between 30% and 50% of their unsubsidized premium, than smokers with no surcharges. 


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