The Effect of Medicaid Smoking Cessation Coverage on Smoking Deterrents Prescriptions

Transcription

1 The Effect of Medicaid Smoking Cessation Coverage on Smoking Deterrents Prescriptions Jie Ma Department of Economics, Indiana University-Bloomington September 12, 2015 Abstract This paper examines the effect of Medicaids smoking cessation coverage on the utilization of smoking deterrents. State Medicaid programs have been expanding smoking cessation coverage in recently years in an attempt to help smokers from low-income families quit smoking. We examine the effect of state Medicaid coverage for four types of cessation interventions: nicotine replacement therapies (NRT), varenicline, bupropion and behavioral counseling, on the prescriptions of smoking deterrents. We utilized a difference-in-differences technique using Medicaid smoking cessation coverage data obtained from Centers for Disease Control and Prevention (CDC)s State Tobacco Activities Tracking and Evaluation (STATE) System and smoking deterrents prescription data from a commercial source-the Pharmaceutical Audit Suite (PHAST) by Symphony Health Solutions. We find that having a complete deterrents coverage significantly increases the use of deterrents by 43.9%, mainly by encouraging the use of NRT and varenicline. Adding coverage for behavioral counseling beyond the complete coverage of deterrents has little impact on deterrents use. Keywords: Medicaid, Smoking Cessation JEL Classification Numbers: I13, I18. Address: 100 S Woodlawn Ave, Bloomington, IN 47408, USA, telephone: , jiema@indiana.edu. The author is grateful to Dr. Kosali Simon, Dr. Hsien-Chang Lin and Dr. Michael Alexeev for advice and suggestions, and Microeconomics workshop participants at the Indiana University for helpful comments. 1

2 1 Introduction Healthy People 2020 sets a goal of reducing the U.S. smoking rate among adults to 12% by As of 2013, the adult smoking rate stood at 17.8% (MMWR 2014b), which is the lowest rate since CDC started collecting these data 50 years ago. Medicaid enrollees smoke at a higher rate than the national average: 30.1% of adult Medicaid enrollees aged 65 years smoke (MMWR, 2014a). Helping smokers to quit successfully is an important way to reduce smoking prevalence. In 2010 while 52.4% of adult smokers made a quit attempt in the past year, only 6.2% had success in quitting (CDC). Smoking cessation interventions, including nicotine replacement therapies (nicotine patch, nicotine gum, nicotine lozenge, nicotine nasal spray and nicotine inhaler, here after NRT), varenicline, bupropion, as well as group counseling and individual counseling, have been shown to effectively increase the possibility of successfully quitting smoking (Fiore etc., 2008). These interventions are also among the preventive services considered highly cost-effective pby whom? (Cromwell etc. 1997). The U.S. Preventive Service Task Force (USPSTF) strongly recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products (USPSTF, 2009). say something here about whether private insurance companies cover these services, and also about how many Medicaid states do this and how fast these state laws have grown over the period of this study However, among those trying to quit smoking in 2010, only 31.7% used counseling and/or medications. Financial incentives provided by health insurance coverage are shown to effectively increase the use of cessation treatments in some settings. Curry et al (1998) used data from a HMO to compare the effects of four different types of cessation coverage. More generous coverage does encourage more use of treatments and result in higher successful quitting rate. Adams et al (2013) looks specifically at the effect of Medicaid coverage on birth outcome and finds that having access to cessation treatments only during pregnancy does not significantly reduce smoking rate or improve birth weight. But having access to treatments 2

3 before pregnancy leads to lower smoking rate and better birth outcome. However, Boyle etc. (2002) finds no impact of a smoking-cessation pharmacy benefit offered by employersponsored health insurance on the use of bupropion, nicotine patches and nicotine gum. No previous studies particularly have looked at the effect of Medicaid coverage on the use of cessation treatments. The Medicaid population has a higher smoking prevalence, higher cessation attempt rates and lower income level, which could potentially lead to different response to cessation coverage compared to private plans. This is an important omission in the literature because Medicaid coverage could potentially help reduce smoking prevalence. By analyzing a specific data set on deterrents prescriptions, this paper examines the effect of Medicaid smoking cessation coverage on the use of smoking deterrents from 2008 to We find that having a complete deterrents coverage significantly increases the use of deterrents by 43.9%, mainly by encouraging the use of NRT and varenicline. Adding coverage for behavioral counseling beyond the complete coverage of deterrents has little impact on deterrents use. Covering only some of the deterrents is not as effective as full drug coverage. Medicaid Smoking Cessation Coverage Medicaid enrollees are more likely to smoke than the general population and Armour etc (2009) estimates that smoking related disease is a major contributor to increasing Medicaid costs: an average of 11.0% and $22 billion for all states in The Affordable Care Act (ACA) requires Medicaid to cover all cessation interventions without cost sharing for pregnant women starting in 2010 and starting January 1st, 2014 smoking deterrents will no longer be excludable by states in their Medicaid outpatient drug formulary. The American Lung Association (ALA) started to track Medicaid coverage of cessation treatments from 2008 (telephone counseling not included). In 2014, only 7 states cover all nine treatments for all enrollees while all 50 states and the District of Columbia provide some cessation coverage for at least some enrollees. Comparing 2008 to 2014, 33 states added treatments to coverage and 22 states removed treatments from coverage (Singleterry 3

4 etc, 2014). Four states consistently provide full coverage of all cessation treatments for general Medicaid enrollees during 2008 and 2014, including Indiana, Massachusetts, Minnesota and Pennsylvania. Several other states provided comprehensive coverage such that at least one NRT deterrent, varenicline, bupropion as well as one counseling program are covered. In 2012, the following 16 states provided comprehensive coverage: Alaska, Arkansas, Connecticut Delaware, Iowa, Michigan, Missouri, Montana, Nebraska, New Hampshire, North Carolina, Oklahoma, Oregon, Rhode Island, Wisconsin and Wyoming. Several states experienced coverage expansion during these years. Five states-alabama, Connecticut, Georgia, Missouri, and Tennessee-started to fully cover pregnant women from 2010 following ACA rules. In addition, Missouri and Tennessee from 2011 and Connecticut from 2012 expanded full coverage to general Medicaid enrollees. States like Rhode Island and Hawaii also expanded their coverage during this period. However, Medicaids increasing Managed Care Organization (MCO) penetration complicates the study of coverage expansion to some extent. Some states specifically exclude cessation intervention from coverage under MCO by writing these exclusions into administration regulations and contracts with MCOs, such as Alabama and Connecticut in Even when coverage is required in contracts, some MCOs did not entirely comply with the requirement. For example, some contracting MCOs in Pennsylvania in 2008 provided only inadequate coverage despite the required full coverage in the contracts. Some states did not explicitly decide cessation intervention coverage in the contracts with MCOs, resulting in varying coverage and confusion for enrollees when comparing across plans. For example, Kentucky, which finally expanded coverage to all enrollees in 2011, moved almost all enrollees to MCOs without explicitly requiring smoking cessation coverage. This resulted in shrinking coverage and confusing information for both patients and healthcare providers. 4

5 2 Data We obtain data on smoking deterrent prescription from the Symphony Institute Pharmaceutical Audit Suite (PHAST). We use prescription information from 2008 to 2014 at month-by-state level. It contains payment information including Medicaid, private, Medicare, cash and others. In particular, the Medicaid payment is separated into fee-for-service and managed care. Details of the drugs included in prescriptions such as the strength form and package size are also available. The information on state Medicaid cessation coverage compiled by ALA has been added to the CDC State Activities Tracking and Evaluation (STATE) System, a database that contains tobacco-related epidemiologic and economic data and information on state tobaccorelated legislation. The STATE provides coverage information separately for fee-for-service Medicaid and MCOs, which differ substantially within states. Several control variables including Medicaid enrollment, smoking bans and taxes that may affect the use of smoking deterrents are obtained from various sources. To control for Medicaid enrollment, I obtain Medicaid total enrollment from Medicaid Statistical Information System (MSIS) at Centers of Medicare and Medicaid Services. Managed care enrollment is also obtained from MSIS by adding enrollment of PCCM, HMO and other MC enrollment together. The information on smoking bans among worksites, restaurants and bars is obtained from State Tobacco Activities Tracking and Evaluation System (STATE) by Centers of Disease Control and Prevention (CDC). Smoking taxes data is collected from Campaign for Tobacco-Free Kids and Tax Foundation. PHAST The Symphony Health Solutions Anonymous Patient Longitudinal Database is a longitudinal patient data source which captures adjudicated prescription claims across the United States across all payment types, including commercial plans, Medicare Part D, cash, as- 5

6 sistance programs, and Medicaid. The data is obtained from ProMetis, a tool healthcare payers and providers use to manage claims of medications, physician services and hospital services. PHAST Prescription Monthly covers over 42,000 retail pharmacies in the sample including mail order and specialty pharmacies. The dispensed prescriptions in the sample represent approximately 82% of all U.S. retail prescriptions (cash, Medicaid, commercial) as well as 60% of all U.S. mail order prescriptions. The retail and mail order prescriptions are projected to the national level. Attempting to compare national total sales and units with PHAST data, I was able to find information on varenicline from 2007 to 2010 in drugs.com Top 100/200 drug lists. The comparison is listed in Table 1. Because varenicline is not in the top 200 list before 2007 and not in the top 100 after 2010, this suggests a U-shaped trend. PHAST data also suggests decreasing trend after 2007 which is consistent with drugs.com. The PHAST sales are close to the national total sales but slightly larger which might be due to the price discount. In addition to the trend, the following part discusses level of prescription. The information we attempt to infer from prescription counts is the number of actual cessation practice. In order to do so, the first is to understand how the deterrents are used in medical practice. Table 2 summarizes the duration and doses of each deterrents in one course of treatment. From Table 2 we can calculate the average duration of each intervention in month. If a range of the duration is given in the guideline, the middle point is used as the average length. For instance, varenicline is suggested for 12 to 24 weeks following the initial 1 week so I take 18 plus one week as the intervention duration. Then we calculate the number of treatments given PHAST data assuming one prescription supplies that deterrent for a month. Combined with adult Medicaid enrollment, the percentage of adult Medicaid enrollees treated can be calculated. Naturally, PHAST data set does not contain all deterrents prescriptions. Since what percentage of prescriptions PHAST captures is unknown, the estimates are expected to be smaller than the actual rates. NHIS 2010 Cancer supplement also provides information that can be used to calculate 6

7 same rates. NHIS data includes 2686 Medicaid enrollees aged 18 or older. Among them 42.67% ever smoked and 27.27% are current smokers. Over 70% of current smokers have tried to quit by stopping smoking for at least one day and 19.32% of former smokers have quitted smoking within a year. Because NHIS interviews spread over 2010 and we can only identify interviewees who tried to quit smoking within a year of the interview, we include the use of deterrents of current smokers who used the cessation interventions within a year and former smokers who quitted within a year. Thus, the actual treatment in NHIS may happen in 2009 and To compensate for this, we use the sum of deterrent counts in 2009 and 2010 in PHAST. Table 3 shows the estimated rates of Medicaid enrollees using smoking deterrents. NHIS estimation is very similar to the reported number in the CDC report and can be considered as the baseline reference. It shows that the most commonly used deterrents are nicotine patch followed by varenicline. The least used deterrent is nicotine spray and inhaler. Although the PHAST estimates are quite different from NHIS estimates, not surprising given all the approximations used to construct PHAST estimates, it shows consistent patterns about the use of deterrents as NHIS. 3 Descriptive Statistics Figure 1 shows the trends in Indiana, Massachusetts and Pennsylvania which started full coverage of smoking cessation treatments before the sample period. The vertical axis is the pre-enrollment prescription. Those three states are the potential control group for this study because their constant coverage during the study period. Since no states remained no coverage due to ACA pregnant women provision, it is not possible to have a no coverage control group. One observation is that with the same coverage, the number of prescription fluctuated. For instance, Massachusettss average prescription in Jan 2010 is only half of that in Dec 7

8 2009. These fluctuations show other factors affect the prescription of deterrents varied over time. However, three states demonstrate similar trends during this period. For example, in Jan 2010, all three states experienced a substantial increase in prescriptions. It indicates that the changes of other relevant factors are likely to be correlated across states. Therefore, the time fixed effects can be effective to capture these underlying changes in deterrents use. This indeed supports the use of the panel model. Figure 2 includes Missouri, Tennessee and Connecticut. As mentioned before, Missouri and Tennessee started to provide all enrollees full deterrents coverage from Figure 2 shows that this policy change was accompanied by a substantial increase in deterrents prescription. Another observation is that with the same coverage, the level of use varies across states. Average prescription in Connecticut is almost four times as that in Tennessee given full deterrent coverage. States must be different in other aspects influencing the use of deterrents and the inclusion of state fixed effects in the model is expected to capture these intrinsic differences. Figure 3 shows the prescription trend for each deterrent type by payment. Not surprisingly, private insurance paid for most of the deterrents. There is a decreasing trend in overall use of smoking deterrents mainly driven by the decrease in varenicline use. Varenicline is the newest smoking deterrents and was patented in Through the study period, there were controversial debate of the effectiveness and safety of this drug. First, there is a 2006 JAMA paper suggests that varenicline is more effective than bupropion and NRT. This might explain the increase in the early years after patented. Second, in Nov 2007, FDA announced depression and suicide as adverse effects of varenicline from post-marketing evidence. And later there are a few further moves regarding the side effects: Feb 2008 FDA further alert; May 2009 update drug safety information and Jul 2009 a black box warning required in the package. These information is likely to contribute to the change in varenicline use. 8

9 4 Methods and Results We use a simple panel model to identify the effect of Medicaid coverage on deterrents prescriptions, controlling for state and year fixed effects. The legitimacy of this model requires the following assumptions. Factors other than control variables influencing the use of deterrents must have similar across-state effects or stable within-state effects for fixed effects to work. For example, the increasing acceptance and awareness of cessation interventions needs to have similar trend among states for year fix effects to work. Also, state-specific factors such as Medicaid program generosity (cost-sharing and coverage for other medical services) and employment rate, have to remain unchanged so that the state fix effects can absorb their impacts. Based on states most common combinations of coverage, we define mutually exclusive categories: (1) states with comprehensive coverage including NRT, medications, and counseling; (2) states with coverage including NRT and medications, but no counseling; (3) states with some form of coverage of NRT, medications, and counseling, but not already represented in categories 1 or 2; and (4) states with no coverage of any type. Group 4 serves as the omitted reference category. The basic regression equation testing the effects of cessation coverage on deterrents use is the following: T rx st = α 1 + α 2 F ull st + α 3 NoCounseling st + α 4 Some st + α 5 ManagedCare st + β X st + γ Ss T RX st is the number of total prescriptions in month t at state s. Log transformation is used so that the coefficients can be interpreted in percentage changed. Explanatory variables include four treatments-the coverage of NRT, varenicline, bupropion and counseling, control variables Xst varying across specifications, state dummies S s and year dummies Tt capturing state specific factors and time trends. In the baseline model no control variables are included. Table 4 reports the results from the basic model with no control variables. Compare to no coverage, having full deterrents coverage significantly increases the prescription by 9

10 43.90% and the additional counseling coverage does not have significant effect on prescription. Specific deterrents wise, the effect is the most substantial on varenicline and NRT. Bupropion use is actually decreased when more drugs are covered. One concern raised from previous analysis is the negative impact of bupropion coverage. As stated before, varenicline and bupropion serves similar function in the cessation treatment and in this period the use of varenicline changes substantially. It is possible that substitution in treatment application cause the negative sign in bupropion prescription. To address this problem, we introduce an additional specification using Medicare or private insurance payment as the control group. Here the identification is a mix of differencein-differences and panel. The coefficients reported below are the coefficients of interaction term of treatment group and coverage indicators. Table 5 reports the results. The signs of the coverage effects are mixed and do not tell consistent stories. From Figure 3, the prescription trends in both Medicare and private insurance are very different from Medicaid and simple year fixed effect may not be able to control for the difference. Case Study In this section I focus on a few states with prominent coverage changes and other Medicaid policy changes. A typical difference-in-differences (DID) method is used with data collapsed into only two periods-before and after the target policy change. Bertrand et al. (2004) suggests that by collapsing several time periods before or after treatment into one, the serial correlation problem can be accounted. The general control states are Indiana and Massachusetts since they have full coverage of all interventions starting before 2008 and did not experience other major changes in Medicaid programs during the sample period. There are no states with zero coverage throughout the study period due to ACA pregnant women provision: at the very least Georgia and Alabama started to cover only pregnant women during this period. The outcome is the logged total prescription. 10

11 Table 6 reports five categories used in later section as the control and treatment groups. Full coverage includes states covering all deterrents during the study period and serving as the control group. Full vs. None is the group of state expanding from no medication coverage to covering all deterrents. This category serves as a robust check of the basic panel model. One vs. All NRT compares NRT coverage of only nicotine patch and all five NRT deterrents. This aspect has not been examined in the previous section. MCO category includes states moving Medicaid to managed care without contracting the cessation coverage. The results of the first set of comparisons between Full vs. None and the control states are presented in Table 8. Connecticut, Missouri and Tennessee started to offer full deterrents coverage in the sample period and Maine greatly shrank its coverage from covering all Medicaid enrollees to only pregnant women in Changing from no coverage to full coverage has a significant large positive impact on deterrents prescription. Connecticut experienced a 200% increase and deterrents use was doubled in Missouri. The effects are all highly significant. The second set of comparisons studies states that changed coverage within NRT category. Oregon shrank coverage of NRT deterrents from covering all five to only nicotine patch in 2011; California covered only NRT patch and bupropion before 2011 and started to cover varenicline in 2011 and all NRT treatments in Table 8 displays the change on total prescriptions and NRT prescriptions for both states; for California, I also report the effect of varenicline coverage and include varenicline prescription as an additional outcome. Expanding coverage from one to five NRT deterrents significantly increases the total prescription and NRT prescription in Oregon. In Californias case, full NRT coverage increases the total prescription only insignificantly and its positive effect on varenicline prescription is rather significant. Surprisingly, it decreases the use of NRT using Massachusetts as the control group. But the coefficient is only marginally significant and no evidence supports this in other specifications. It is likely to be only an outlier in the data. Varenicline coverage has an even stronger effect on both NRT and varenicline in California. 11

12 5 Conclusion and Limitations Using data from a prescription drug dataset, PHAST, this study analyzes the effect of Medicaid smoking cessation coverage on the use of smoking deterrents from 2008 to The main finding from a panel model pooling data across all states suggests that varenicline coverage significantly increases the use of smoking deterrents by 73.4%. NRT coverage, though not consistently significant across all estimated model, also shows a large positive impact of 27.2% on the use of deterrents. This suggests that cessation coverage is indeed a highly effective way to encourage the use of cessation interventions and thus contributes to the task of reducing smoking prevalence. By examining selected states separately, we also provide evidence about effects of NRT coverage variation and MCO penetration. It is shown that covering more NRT deterrents is potentially beneficial. Patients having the choice of different nicotine replacements are more willing to use smoking deterrents. In addition, despite the common belief that managed care usually provide better preventive services, MCOs are not guaranteed to provide the comprehensive coverage of cessation interventions. It is very important to specify the exact coverage when Medicaid negotiates the contract with MCOs. Various robustness checks are preformed to boost confidence of the results. Falsification tests ensure that the results are not likely to be replicated with irrelevant treatments and outcomes. Especially, pseudo outcome using deterrents prescriptions paid by cash, assistance program, commercial insurance and Medicare suggests the likelihood of Medicaid substituting for payment of other sources. The counter-intuitive results of bupropion coverage suggest that one limitation of the current study might be that state and year fixed effects are not sufficient to absorb the trend and variations in deterrents use due to other factors. As discussed above, the medical practice states to substitute bupropion with varenicline and this process may not be uniform in different states. Since our data is at state level, controlling for more fixed effects such as interacted time-state ones intensifies the multi-collinearity problem. Ideally, some measures 12

13 of bupropion-varenicline substitution can be taken to control for this factor. Another limitation is on PHAST dataset. As Table 3 suggests, PHAST does not capture the large majority of cessations paid by Medicaid. As we do not know how data are selected into PHAST, the analysis may suffer from representativeness issue. Also, since the exact drug doses prescribed by each prescription are unknown, the outcome variables used in the paper are subject measurement errors. However, the estimation using weighted prescription and Poisson model provides reference on the measurement issue. According to the results of this study, ACA provision in 2014 of deterrents drug coverage is quite promising to encourage the use of deterrents. The current ACA rule states that smoking deterrents will no longer be excludable in Medicaid outpatient drugs coverage after Jan 1st, But in word and also practice, no exclusion does not necessarily imply inclusion. Further explanation needs to clarify this to make the most use of cessation coverage. One natural question following the current study is to understand the decisions of quitting smoking and the resulting success rates due to expanded coverage and increased deterrents use. In particular, how much increase in the deterrents is due to increased decision to quit smoking. In addition, because some of the medications are also available over-the-counter (OTC), it is interesting to examine the total effect combining prescription and OTC together for NRT medications. 13

14 References 14

15 Figure 1: Total Prescription in Indiana, Massachusetts and Pennsylvania Note: This figure plots the total prescription in Indiana, Massachusetts and Pennsylvania from 2008 to These three states had full treatment coverage during this time period. To account for data reporting time variation, we use 3-month moving average here. Colors only show in electronic version. 15

16 Figure 2: Total Prescription of Missouri, Tennessee and Connecticut Note: This figure plots the total prescription in Tennessee, Connecticut and Missouri from 2008 to These states cover no cessation interventions before 2008 and expanded to full deterrents coverage by To account for data reporting time variation, we use 3-month moving average here. Colors only show in electronic version. 16

17 Figure 3: Prescription for Each Deterrent Type by Payment Note: This figure plots the total count of smoking deterrents prescription and for each deterrent type by payment. Colors only show in electronic version. 17

18 Table 1: Compare National Total of Varenicline Drugs.com PHAST Drug Year Sales Units TRx Dollars TRx Count Chantix(Varenicline) 2013 Not in top 100 $526,869, ,342,503 Patented in Not in top 100 $484,792, ,542, Not in top 100 $471,903, ,853, ,944,000 2,980,000 $468,730, ,252, ,207,000 3,861,000 $540,720, ,066, ,323,000 5,381,000 $697,369, ,678, ,723,000 7,302,000 $857,294, ,705, Not in top Not in top Not in top Not in top 200 Note: The drug.com information is from lists of the top 200 pharmaceutical drugs by retail sales in 2010, listed by U.S. sales value and brand name. ( 18

19 Smoking Deterrents Table 2: Smoking Deterrents in Practice Practice Nicotine Patch Initial 21 mg/day for 4-6 weeks Follow 1 14 mg/day for 2 weeks Follow 2 7 mg/day for 2 weeks Nicotine Gum/Lozenge Initial 2-4 mg every 1-2 hours for 6 weeks Follow taper gradually over 6 months Or 2-4 mg when required, taper gradually max 30 mg/day Nicotine Inhaler Initial mg/day for 12 weeks Follow taper gradually over 12 weeks Nicotine Nasal Spray 0.5 mg (1 spray) once or twice an hour when required max 80 sprays/day Bupropion Initial 150 mg/day for 3days Follow 150 mg twice daily for 8 weeks (300mg/day) Varenicline Initial 0.5 mg/day for 3 days Follow mg twice daily for 4 days (1 mg/day) Follow 2 1 mg twice daily for weeks (2 mg/day) Note: This table summarizes the duration and doses of deterrents used in practice. Medical guideline information is obtained from Epocrates. Original source checked when provided. ( 19

20 Table 3: Percentage of Adult Medicaid Enrollees Treated in 2010 NHIS PHAST Treatment Rate Standard Deviation Rate Standard Deviation Nicotine Patch 2.53% % Nicotine Gum & Lozenge 1.30% % Nicotine Spray & Inhaler 0.15% % Varenicline 1.71% % Bupropion 0.63% % Total 6.33% 0.88% Note: This table displays the percentage among adult Medicaid enrollees using smoking deterrents to quit smoking in 2009 and It compares the rates reflected in NHIS 2010 cancer module and PHAST. Adult Medicaid enrollment is obtained from Kaiser Database. 20

21 Treament NRT and medication, no counseling Table 4: Panel Regression with Grouped Treatment Definition Outcomes Total Count NRT Varenicline Bupropion *** *** *** *** ** *** Quan- Total tity NRT, medication and counseling Some cessation coverage R N Note: This table shows the effects of Medicaid smoking cessation coverage on the number of total deterrents prescriptions. The numbers represent the estimated percentage change and standard errors are clustered in the state level. State and year fixed effects are included. *p < 0.1; ** p < 0.05; *** p <

22 Table 5: Panel Regression with Medicare and Private Insurance as Control Groups NRT, medication and counseling NRT and medication, no counseling Medicare as Control ** *** (0.065)) Some cessation coverage R N Private as Control Note: This table shows the effects of Medicaid smoking cessation coverage on the number of total deterrents prescriptions using Medicare and private insurance payment as the control group. The numbers represent the estimated percentage change and standard errors are clustered in the state level. State and year fixed effects are included. *p < 0.1; **p < 0.05; *** p <

23 Table 6: Summary of Medicaid Cessation Coverage Full Coverage Full vs. None One vs. All NRT MCO Others Indiana Connecticut Oregon Kentucky Florida Massachusetts Maine California New York Hawaii Pennsylvania Missouri Nebraska Tennessee Ohio Texas Note: This table summarizes states with prominent coverage changes during the sample period. 23

24 Table 7: Full vs. None Comparison Missouri Connecticut Tennessee Maine Indiana (0.116)*** (0.140)*** (0.218)*** (0.216)*** Massachusetts (0.091)*** (0.104)*** (0.197)*** (0.195)*** N Note: This table reports the percentage change of deterrents prescription between no coverage and full deterrents coverage. Standard errors are in parentheses. *p < 0.1; **p < 0.05; *** p <

25 Table 8: One vs. All NRT Comparison Oregon California Coverage Total TRx NRT TRx Total TRx NRT TRx Varenicline TRx Indiana NRT (0.108)* (0.139)*** (0.226)* Varenicline (0.183)*** (0.214)*** (0.185)*** MassachusettsNRT (0.081)*** (0.096)*** (0.214)* (0.192)** Varenicline (0.158)*** (0.174)*** (0.156)*** N Note: This table reports effects of full NRT coverage compared to covering only one NRT deterrent on total and NRT prescription. The effect of varenicline coverage and NRT coverage on varenicline prescription is also reported for California. Standard errors are in parentheses. *p < 0.1; **p < 0.05; *** p <