Jackson • An in-depth analysis of Mississippi Medicaid claims estimates tobacco use costs the program nearly $400 million a year.
Based on the detailed estimates, Mississippi’s share of the tobacco-attributed health care costs is around $90 million; federal allocations cover 77 percent of Medicaid costs.
“It’s really a very conservative estimate,” said Therese Hanna, executive director of the nonpartisan, independent Center for Mississippi Health Policy, which commissioned the report.
Researchers at the Hilltop Institute of University of Maryland-Baltimore County reviewed Mississippi Medicaid claims from 2016 and 2017 to develop a more accurate picture of what tobacco-attributed conditions costs Medicaid.
“No one had ever tried to precisely measure it,” Hanna said.
The estimated direct and indirect cost of tobacco-related illness was $387.95 million, 8.8 percent of the total $4.4 billion Mississippi Medicaid health expenses in 2016 and $395.93 million, 9.2 percent of $4.3 billion in 2017.
The tobacco expense report was among the items presented this week during a state Senate Medicaid committee hearing by Dr. Steve Demetropoulos, who serves as the chairman of the state Medicaid Medical Advisory Board.
“This is as close as you can get for real time data for this population,” said Tupelo pulmonologist Dr. Jim Rish, a member of the advisory board. “I hope they pay attention to it.”
The report confirms there’s a significant opportunity to improve the health of the state, said State Sen. Hob Bryan, D-Amory, who is a member of the Medicaid committee.
“It’s hard to imagine any other public health (issue) that could do more to improve the (Mississippi’s) health than reducing the number of people smoking,” Bryan said.
A hypothetical model with a 10 percentage point reduction in the number of tobacco users in the Medicaid population – from 33 percent to 23 percent – would have a significant reduction in tobacco-related costs. Using the 2016 and 2017 data, a smaller percentage of smokers would have reduced expenditures about 27 percent – to $282 million in 2016 and $288 million in 2017.
In its issue brief, the center, which does not lobby or advocate, presented four policies that Mississippi leaders may want to consider as ways of decreasing the financial and health impacts of tobacco.
Improved tobacco cessation support and coverage could be helpful as surveys of smokers indicate most wish to quit. Currently, Medicaid only covers cessation counseling for pregnant women, but it does cover FDA-approved treatments for its members.
Smoke-free ordinances and laws could be helpful. Multiple studies, including research done in Mississippi, have shown that heart attacks decrease in cities where smoke-free ordinances were implemented, Hanna said. Although many cities have implemented indoor smoking bans, it would likely require state action to cover unincorporated areas.
Tobacco tax increases have been effective in other states, particularly at reducing the number of underage and young adult smokers. Mississippi’s current 68-cent-per-pack tax is well below the national average of $1.78. A Mississippi coalition is currently advocating for an increase to a $2.18 tax/user fee per pack. If any funds from tobacco tax increases are focused on Medicaid, it could be helpful at offsetting tobacco-related expenses, Rish said.
“It’s not unreasonable to try to focus the tax burden on the ones consuming the resources,” Rish said.
Raising the minimum legal age to purchase tobacco to 21 could also be effective, according to the National Academy of Medicine. It reduces access for youth, protecting developing brains. It also would be expected to have a long-term reduction in smokers because few people start smoking after age 21. A Massachusetts town saw nearly a 50-percent decrease in smoking among high school students in the four years after raising the minimum legal age.
Whatever steps the legislature takes, Bryan would like to see all forms of tobacco, as well as e-cigarettes, included in the measures. The last time the cigarette tax was increased, smokeless tobacco wasn’t included and vaping didn’t exist.
“They are all bad for public health,” Bryan said.
Although Bryan would like to see the state’s tax structure rebalanced before adding any new taxes, he is open to debate on the measures.
“These are sensible proposals we need to discuss,” Bryan said. “It’s the sort of things we should be considering.”
More than lung cancer
The health impacts of tobacco go beyond lung cancer and emphysema.
“Tobacco has such a widespread impact on the body,” Hanna said.
The report looks at the medical expenditures on 14 categories of cancers, six categories of cardiovascular disease, five categories of respiratory diseases and six other diseases that are impacted by tobacco including Type II diabetes, hip fractures, rheumatoid arthritis, macular degeneration, Alzheimer’s disease and pre or perinatal conditions.
“We looked where the evidence was clear,” Hanna said. “We know there are other diseases that we could justify, but no one has done the research” to quantify tobacco’s impact.
Most of the data is derived from studies that looked at cigarette smoking, said the report’s lead researcher Charles Betley. The smokeless tobacco risks are incorporated in oral and throat cancers. No data was included on vaping and e-cigarettes; it will be decades before the risk can be quantified in the same was as cigarette smoking.
“We may not have captured all the smoking impact,” Betley said.
The tobacco-related costs were determined by multiplying the sum of claims payments for each disease by a smoking attributable fraction, which is based on Mississippi’s rate of smoking and research literature estimates of the relative risk for that disease connected to smoking or tobacco use. Using data from Centers for Medicare and Medicaid survey of Medicaid members, the researchers used 33.8 percent as the rate of smoking for the population.
Neither lung cancer or emphysema were the most expensive conditions for Mississippi Medicaid. The highest estimated for tobacco-attributed costs was for stroke at $56.7 million in 2016 and $57.9 million in 2017. The costs for coronary heart disease were estimated at $16.3 million in 2016 and $16.9 million in 2017.
The estimated tobacco attributed amounts for tracheal, lung and bronchial cancer was $6.7 million in 2016 and $7.2 million in 2017. The estimates of smoking bronchitis and emphysema came in at $3.7 million in 2016 and $3.8 million in 2017. COPD had the highest estimated expenses at $41 million in 2016 and $45 million in 2017.
Young children who don’t smoke and teens who have started smoking typically haven’t developed cancer, lung or heart disease due to smoking, but their health is impacted by smoking, according to the report. Smoking can contribute to premature birth, which often requires expensive neonatal intensive care. Second-hand smoke elevates the risk of childhood asthma and other diseases.
Asthma and asthma medications costs for both adults and children were estimated at at $14.9 million in 2016 and $11.6 million in 2017. Neonatal intensive care costs were estimated at $7.4 million in 2016 and $7.1 in 2017.
The study included some costs for nursing facility care but was adjusted to reflect that most acute care for that population is covered by Medicare. It estimated the tobacco-attributable costs for nursing care were $124.9 million in 2016 and $123.5 million in 2017.
Figures for the percentages of smoking attributable expenses have been corrected in this story.