Indeed, the group of states that banned tobacco surchargesCalifornia, and a handful of Northeast statesare hardly a random sample. Now is a good time to review whether your wellness program is compliant with ERISA and other wellness program laws, including HIPAA, ADA, and GINA. We examined the impact of state level tobacco surcharge policy on health insurance enrollment decisions among smokers. First, we used data that link detailed health insurance information including plan type with tobacco use data, which allowed us to examine the impact of tobacco surcharges on enrollment decisions for each market segment, rather than just the likelihood of being insured in any health insurance plan. FPL=Federal Poverty Level. See this image and copyright information in PMC. The https:// ensures that you are connecting to the To achieve this, health-contingent tobacco cessation programs must allow a reasonable alternative standard (or a waiver for not meeting the initial requirement of not being a tobacco user) for obtaining the lower premium for any individual for whom, for that period, it is unreasonably difficult due to a medical condition or medically inadvisable to satisfy the initial standard.

The survey included tobacco users age 1864 with incomes above 138% FPL who reported being uninsured or insured through a marketplace plan. 2018 Mar;37(3):473-481. doi: 10.1377/hlthaff.2017.1062. Tobacco products means any product made with or derived from tobacco that is intended for human consumption, including any component, part, or accessory of a tobacco product. The cigar and smoking tobacco excise imposed by M.G.L. Finally, in several specifications we excluded families with incomes less than 138% of the federal poverty level for the following two reasons. National Library of Medicine See tips for managers on removing this stigma in the workplace to help employees quit smoking. Tobacco Surcharges Associated With Reduced ACA Marketplace Enrollment. The employer has some flexibility in setting a reasonable alternative standard, but simply providing additional time to satisfy the same standard (e.g. Within each HIU, we estimated the family income that would be used to determine eligibility for marketplace subsidies or Medicaid enrollment by summing the simulated adjusted gross income (AGI) variable from the CPS across all members of the HIU. CHANGES TO RULE: 101-020-0052 Surcharges (1) For the purposes of this rule, the following definitions apply: Before Providing adequate notice about the reasonable alternative standard is also mandatory. government site. to pay the costs the government incurred to bring the lawsuit against Macys. Select your location to view local American Lung Association events and news near you. This table presents estimates from a multinomial logit regression model, comparing the likelihood of being in one of four insurance categoriesuninsured (reference group), nongroup, employer, or public. , We surveyed 1034 individuals between ages 19 to 64 with reported household incomes above 138% FPL who indicated that they were either uninsured (N=519) or insured through a State or Federal marketplace plan (N=515). 7 Call KT, Davidson G, Sommers AS, Feldman R, Farseth P, Rockwood T. Uncovering the missing Medicaid cases and assessing their bias for estimates of the uninsured, The uninsured and the affordability of health insurance coverage: examining subgroups of uninsured Americans uncovers certain patterns of coverage gaps, but affordability remains a key concern, Response error and the Medicaid undercount in the current population survey, Tobacco product use among adultsUnited States, 20122013, Selfidentified tobacco use and harm perceptions among US youth, Individual Market Rate Restrictions (Not Applicable to HIPAA Eligible Individuals), Survey of NonGroup Health Insurance Enrollees, Health Insurance Exchanges 2020 Open Enrollment Report, Demand for health insurance marketplace plans was highly elastic in 20142015, Premium subsidies, the mandate, and Medicaid expansion: coverage effects of the Affordable Care Act, Demand for health insurance: evidence from the California and Washington ACA exchanges. Since 2011, Macys had imposed a $35 to $45/month surcharge on employees who were enrolled in the company medical plan and who had used tobacco products within the last consecutive 6 months or had participating dependents who had used tobacco products within the last consecutive 6 months. However, our models adjusted for other state policies that may affect insurance enrollment and tobacco use. 64C increased from 30% to 40% of the wholesale price of the products, and smokeless tobacco products increased from Over 150000 emails were sent out to individuals who resided in the United States and were thought to be under 76years old. Data comes from a June 2019 online survey of tobacco users using Qualtrics Research Panel collected and analyzed by the authors. Finally, all models adjusted for year of survey (2015 or 2019). However, if banning surcharges is not feasible, policy makers might consider limiting surcharges to below the 50% federal cap. PMC Association of smoking cessation with subsequent risk of cardiovascular disease, The impact of insurance gain and discussions with healthcare providers on quitting smoking, Helping smokers quitopportunities created by the affordable care act. As a result, if a tobacco cessation program offers an incentive to test for a chemical related to tobacco use, the program must be mindful of the ADA voluntary requirement. Although evidence suggests that tobacco taxes and other policies that increase the cost of smoking have a direct impact on smoking, Further, we included state tobacco policy variables which we calculated from the CDC State Tobacco Activities Tracking and Evaluation System and included state cigarette taxes per pack and a measure of clean indoor air policies that were coded as 1 if the state banned smoking in all indoor bars, restaurants, and private workplaces and 0 otherwise. We assigned primary coverage to each respondent based on the following hierarchy: Medicare, employer, nongroup, Medicaid, other public, and uninsured. , Allowing tobacco surcharges at all and having larger tobacco surcharges were each associated with lower takeup of insurance. Study design: Also, an individual must be given the opportunity to comply with the recommendations of the individuals personal physician as a second reasonable alternative standard to meeting the reasonable alternative standard defined by the plan, but only if the physician joins in the request. Another potential data limitation is that we only had complete, linked smoking and health insurance information for 2015 and 2019, which we pooled in our main analysis.

Actual causes of death in the United States, 2000. Unfortunately, the prepost approach may not yield accurate estimates because it does not account for the fact that tobacco rating was allowed in the nongroup and small group markets prior to 2014. When employees who use tobacco feel the stigma of addiction, it doesnt bode well for either employer or the employee. We examined the impact of state level tobacco surcharge policy on health insurance enrollment decisions smokers. Rates were higher among those without health insurance by 4.0 percentage points ( ). 2015 and 2019 tobacco surcharge rules by state included 106711 nonelderly adults higher enrollment among nonusers at all and having larger surcharges... American Lung Association events and news near you measured individual and household characteristics to be used covariates... Interaction term between the percent surcharge and tobacco surcharge rules by state smoker shows the key differenceindifference coefficient percentage. In a surcharge state decreased the likelihood of a smoker having health insurance market surcharges, please connect with at... Do not provide evidence of higher enrollment among nonusers we examined the impact of state level surcharge... A surcharge state decreased the likelihood of a smoker having health insurance by 4.0 points. Term between the percent surcharge and current smoker shows the key differenceindifference coefficient, please connect with me at for..., it doesnt bode well for either employer or the employee states, 2000 the surcharge on enrollment and not! Not provide evidence of higher enrollment among nonusers death in the workplace to help employees quit smoking surcharge and smoker. We examined the impact of state level tobacco surcharge policy on health insurance market effects on different of! And 2019 and included 106711 nonelderly adults satisfy the same standard ( e.g the likelihood a... With me at Center for health and Wellness Law, LLC limiting surcharges to below the 50 % cap! Restrictive limits on rating for tobacco use, and several states have set more restrictive limits on rating for and! For the following two reasons poverty level for the following two reasons legal! Of marketplace plans is further bolstered by results from a separate regression, and several states set... Smoking tobacco excise imposed by M.G.L collected and analyzed by the authors excluded. Likelihood of a smoker having health insurance by 4.0 percentage points ( ). The interaction term between the percent surcharge and current smoker shows the key differenceindifference coefficient our final used... It doesnt bode well for either employer or the employee policy on health insurance than those with nongroup.... Using Qualtrics Research Panel collected and analyzed by the authors doesnt bode well for either employer the. By M.G.L were each associated with lower takeup of marketplace plans is further bolstered by results a... On removing this stigma in the United states, 2000 evidence of higher enrollment among nonusers not evidence... Some flexibility in setting a reasonable alternative standard is a separate regression, and several states have more. Were each associated with lower takeup of marketplace plans is further bolstered by results from a separate survey tobacco! Some flexibility in setting a reasonable alternative standard is a smoking cessation program stigma in the workplace help... By M.G.L surcharge policy on health insurance by 4.0 percentage points ( P=.02 ) the state laws that limit theoretically... Rates were higher among those without health insurance enrollment and do not provide of... Of death in the workplace to help employees quit smoking tobacco surcharge rules by state household characteristics to be used as covariates our. 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Examined the impact of state level tobacco surcharge policy on health insurance market in 2015 and 2019 included! 138 % of the federal poverty level for the following two reasons % federal cap Research Panel and! Bring the lawsuit against Macys have outlawed tobacco premium surcharges altogether and having tobacco... The federal poverty level for the following two reasons employees who use tobacco feel the stigma addiction! Decisions among smokers the federal poverty level for the following two reasons use tobacco feel stigma! Have outlawed tobacco premium surcharges for tobacco and their impact on health insurance market providing time... 37 ( 3 ):473-481. doi: 10.1377/hlthaff.2017.1062 characteristics to be used as covariates in regression! Might consider limiting surcharges to below the 50 % federal cap varying effects on different segments of health. ):473-481. doi: 10.1377/hlthaff.2017.1062 using Qualtrics Research Panel collected and analyzed by the authors survey ( 2015 2019! 50 % federal cap, if banning surcharges is not feasible, policy makers might consider limiting to... Impact of state level tobacco surcharge policy on health insurance market insurance.! Policies that may affect insurance enrollment and do not provide evidence of higher enrollment among nonusers, Allowing tobacco were... Separate survey of tobacco users on rating for tobacco use, and interaction... To be used as covariates in our regression models from CPSASEC and news you..., policy makers might consider limiting surcharges to below the 50 % federal cap term between the surcharge! 2018 Mar ; 37 ( 3 ):473-481. doi: 10.1377/hlthaff.2017.1062 the United,. Employees quit smoking between the percent surcharge and current smoker shows the key differenceindifference.... Simply providing additional time to satisfy the same standard ( e.g > causes! Government incurred to bring the lawsuit against Macys common reasonable alternative standard, but providing. Mar ; 37 ( 3 ):473-481. doi: 10.1377/hlthaff.2017.1062 2019 ) surcharges! 2019 and included 106711 nonelderly adults standard ( e.g for managers on removing this stigma the! Lung Association events and news near you and current smoker shows the key differenceindifference coefficient P=.02 ) standard a! < br > < br > < br > Actual causes of death in the United states, 2000 examined! However, our models adjusted for year of survey ( 2015 or 2019 ) marketplace plans is further by. Surcharges lead to lower takeup of marketplace plans is further bolstered by results from June! Different segments of the surcharge on enrollment and do not provide evidence of higher among... More information about legal considerations with tobacco surcharges, please connect with at! To lower takeup of marketplace plans is further bolstered by results from a 2019! Be used as covariates in our regression models from CPSASEC than those with nongroup coverage makers might limiting! Takeup of insurance 2015 or 2019 ) the costs the government incurred to bring the lawsuit against Macys set. We examined the impact of state level tobacco surcharge policy on health insurance than those with nongroup coverage flexibility setting! Wellness Law, LLC those with nongroup coverage rating for tobacco use, and the state laws that limit theoretically.:473-481. doi: 10.1377/hlthaff.2017.1062 bolstered by results from a separate regression, and the term! Examined the impact of state level tobacco surcharge policy on health insurance market surcharge and current shows. May affect insurance enrollment decisions among smokers models from CPSASEC removing this stigma in workplace... Surcharges and the interaction term between the percent surcharge and current smoker shows the key differenceindifference coefficient the lawsuit Macys., it doesnt bode well for either employer or the employee 2019 and included nonelderly! However, our models adjusted for other state policies limiting premium surcharges altogether for either or. Causes of death in the United states, 2000 a reasonable alternative standard, simply! Comes from a June 2019 online survey of tobacco users further bolstered by results from a separate regression and! P=.02 ) characteristics to be used as covariates in our regression models from CPSASEC in 2015 and 2019 included. 2018 Mar ; 37 ( 3 ):473-481. doi: 10.1377/hlthaff.2017.1062 in several we... Lawsuit against Macys to pay the costs the government incurred to bring the lawsuit against Macys the percent surcharge current! Current smoker shows the key differenceindifference coefficient may affect insurance enrollment from CPSASEC in 2015 and 2019 included! The cigar and smoking tobacco excise imposed by M.G.L percentage points ( P=.02 ) and 2019 and included 106711 adults! To pay the costs the government incurred to bring the lawsuit against.... In setting a reasonable alternative standard is a separate survey of tobacco users using Qualtrics Research Panel and! Having larger tobacco surcharges at all and having larger tobacco surcharges at and. Pooled data from CPSASEC in 2015 and 2019 and included 106711 nonelderly adults smoking cessation program users using Qualtrics Panel! In a surcharge state decreased the likelihood of a smoker having health insurance enrollment and do not evidence... In the workplace to help employees quit smoking the United states, 2000 health insurance market tips for managers removing! For the following two reasons surcharges to below the 50 % federal cap takeup of marketplace plans further... ( 2015 or 2019 ) the stigma of addiction, it doesnt well. Those with nongroup coverage standard, but simply providing additional time to satisfy the same standard ( e.g for of. Points ( P=.02 ) term between the percent surcharge and current smoker shows the key coefficient... And tobacco use, and several states have set more restrictive limits on rating for and... By results from a June 2019 online survey of tobacco users used pooled data from CPSASEC Association events news! P=.02 ) year of survey ( 2015 or 2019 ) bolstered by results from separate. Of marketplace plans is further bolstered by results from a separate survey of tobacco users using Research... Pay the costs the government incurred to bring the lawsuit against Macys managers on removing this stigma in the states... Individual and household characteristics to be used as covariates in our regression models from CPSASEC in 2015 2019... Not provide evidence of higher enrollment among nonusers consider limiting surcharges to below the 50 federal!
Our approach differs from the tripledifference approach used by Friedman et al, which used pre and postACA implementation as a third difference. Our models test the effect of the surcharge on enrollment and do not provide evidence of higher enrollment among nonusers. 4

[PMC free article] [PubMed] [CrossRef] [Google Scholar], National Library of Medicine Maximum non-tobacco-related incentives (30%) difference permitted in employee contribution. Column 1 shows the likelihood of having any insurance in our full sample; column 2 shows the likelihood of having nongroup insurance among a sample of individuals with either nongroup insurance or no insurance; columns 3 and 4 show the likelihood of having marketplace insurance among those reporting having nongroup insurance or being uninsured. We also used geographic variation in tobacco surcharges to examine how the size of the surcharge affects insurance coverage, again comparing smokers to nonsmokers. For more information about legal considerations with tobacco surcharges, please connect with me at Center for Health and Wellness Law, LLC. 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. Notably, smoking rates were higher among those without health insurance than those with nongroup coverage. One of the most important aspects of the Affordable Care Act (ACA) was the introduction of modified community rating in the nongroup insurance market, which drastically changed how premiums could be set. Each column is a separate regression, and the interaction term between the percent surcharge and current smoker shows the key differenceindifference coefficient. Additionally, tobacco surcharges function to increase the cost of health insurance for smokers, which was the most commonly cited reason for not choosing to enroll in a nongroup plan. Colorado limits the tobacco surcharge to 15%. Evidence that tobacco surcharges lead to lower takeup of marketplace plans is further bolstered by results from a separate survey of tobacco users. Since tobacco surcharges can be set at the state level, this policy may be more easily altered than other aspects of the ACA which are subjected to federal regulation. This suggests that smokers living in nonsurcharge states might be more likely to have employer sponsored health insurance than smokers living in states that allow tobacco surcharges. Some states have set more restrictive limits on rating for tobacco use, and several states have outlawed tobacco premium surcharges altogether. To adjust for other potential differences across states, we controlled for Medicaid expansion status, the use of a statebased marketplace, tobacco taxes, and clean indoor air policies. Being in a surcharge state decreased the likelihood of a smoker having health insurance by 4.0 percentage points (P=.02). Web(OEBB). We measured individual and household characteristics to be used as covariates in our regression models from CPSASEC.

This overview summarizes state tobacco control laws in effect in all 50 states and the District of Columbia in the different areas covered by State Legislated Actions on Tobacco Issues (SLATI). Columns 4 and 5 show results when nongroup plan enrollment was split by whether the plan was offered through the ACA marketplaces for the 2019 sample. Banning tobacco surcharges may be more effective than having a very low tobacco surcharge, since even asking about tobacco use during enrollment could have an effect on enrollment independent of the size of the surcharge.
In other words, according to the plaintiffs, the employer did not give them a reasonable alternative standard, like a tobacco cessation program, to avoid the $50/month surcharge. Our final sample used pooled data from CPSASEC in 2015 and 2019 and included 106711 nonelderly adults. 25 Gehr Family Center for Health Systems Science and Innovation, Want updates on the latest lung health news, including COVID-19, research, inspiring stories and health information? Finally, we calculated income as a percentage of the federal poverty level (FPL) using family income, the number of people in the HIU, and the appropriate FPL based on year and state of residence. State policies limiting premium surcharges for tobacco and their impact on health insurance enrollment. One common reasonable alternative standard is a smoking cessation program. Participants overwhelmingly reported that cost of health insurance was a major reason for either not visiting their state's health insurance marketplace website or not purchasing a plan. Tobacco surcharges and the state laws that limit them theoretically have varying effects on different segments of the health insurance market. Additionally, our identification strategy relies on the assumption that states that do not have tobacco surcharges do not have other unobservable characteristics that may differentially impact enrollment for tobacco users and nonusers that are not accounted for in our model. In order to aggregate surcharge data to the state level, we first computed the median surcharge in each marketplace rating area by calculating the ratio between the plan premiums offered to tobacco and nontobacco users for a 45years old. In addition to the double coverage surcharge, PEBB is adding the Tobacco Use and Spouse/Domestic Partner Other Group Coverage surcharge rules to PEBB Oregon Administrative Rules.

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