State policies limiting premium surcharges for tobacco and their impact on health insurance enrollment

• Published in: Health services research Vol. 55; no. 6; pp. 983 - 992
• Main Authors: Kaplan, Cameron M., Kaplan, Erin K.
• Format: Journal Article
• Language: English
• Published: United States Health Research and Educational Trust 01.12.2020; Blackwell Publishing Ltd; John Wiley and Sons Inc
• Subjects: affordable care act; Best of AcademyHealth 2020 Annual Research Meeting; Best of Arm 2020; Comparative analysis; Data collection; Demographic aspects; enrollment; Enrollments; Geographical variations; Government regulation; Health aspects; Health insurance; Health insurance industry; Health status; Humans; Insurance; Insurance coverage; Insurance Coverage - statistics & numerical data; Insurance, Health - statistics & numerical data; Laws, regulations and rules; marketplace; Nonsmokers; Patient Protection and Affordable Care Act - legislation & jurisprudence; Polls & surveys; Premiums; Qualitative analysis; Smoker-Nonsmoker interactions; Smokers; Smoking; State Government; State policies; Surcharges; Taxes - legislation & jurisprudence; Tobacco; Tobacco Products - economics; Tobacco Products - legislation & jurisprudence; tobacco surcharge; United States; United States; California; tobacco surcharge; marketplace; health insurance; smoking; premiums; affordable care act; enrollment
• ISSN: 0017-9124; 1475-6773; 1475-6773
• DOI: 10.1111/1475-6773.13577

Objective The Affordable Care Act allows insurers to charge up to 50% higher premiums to tobacco users, making tobacco use the only behavioral factor that can be used to rate premiums in the nongroup insurance market. Some states have set more restrictive limits on rating for tobacco use, and several states have outlawed tobacco premium surcharges altogether. We examined the impact of state level tobacco surcharge policy on health insurance enrollment decisions among smokers. Study Design We compared insurance enrollment in states that did and did not allow tobacco surcharges, using a difference‐in‐difference approach to compare the policy effects among smokers and nonsmokers. We also used geographic variation in tobacco surcharges to examine how the size of the surcharge affects insurance coverage, again comparing smokers to nonsmokers. Data Collection We linked data from two components of the Current Population Survey—the 2015 and 2019 Annual Social and Economic Supplement and the Tobacco Use Supplement, which we combined with data on marketplace plan premiums. We also collected qualitative data from a survey of smokers who did not have insurance through an employer or public program. Principal Findings Allowing a tobacco surcharge reduced insurance enrollment among smokers by 4.0 percentage points (P = .01). Further, smokers without insurance through an employer or public program were 9.0 percentage points less likely (P < .01) to enroll in a nongroup plan if they were subject to a tobacco surcharge. In states with surcharges, enrollment among smokers was 3.4 percentage points lower (P < .01) for every 10 percentage point increase in the tobacco surcharge. Conclusions Tobacco use is the largest cause of preventable illness in the United States. State tobacco surcharge policy may have a substantial impact on whether tobacco users choose to remain insured and consequently their ability to receive care critical for preventing and treating tobacco‐related disease.