Trends in Employer-Sponsored Health Insurance Coverage for Tobacco-Dependence Treatments

Background 

It is well-known that tobacco use is the single most preventable cause of death and disability in the U.S. Despite this, an estimated 20.8% of the U.S. adult population are current smokers, leading to approximately 438,000 premature deaths annually.1, 2 Smokers have higher rates of cancer, heart disease, and respiratory disease compared to nonsmokers.2 It is estimated that the total cost of tobacco use exceeds $176 billion per year.2

A recent systematic review3 concluded that tobacco-use screening combined with brief intervention is one of the three most valuable clinical preventive services. From a societal perspective, treating tobacco dependence has been shown to be cost effective; from an employer's perspective, tobacco-dependence treatments (TDTs) are even cost-saving.3, 4, 5, 6 A Cochrane review on the relationship between insurance coverage and the use of TDTs found that, overall, insurance coverage for TDTs leads to a reduction in tobacco use.7 In 2000, the U.S. Public Health Service (PHS) published a clinical practice guideline, Treating Tobacco Use and Dependence, based on a comprehensive review of the published scientific literature on the effectiveness of different treatments.8 The PHS guideline recommends coverage for three types of treatment that have proven to be effective in treating tobacco dependence: nicotine replacement therapy (NRT); bupropion SR (brand name Zyban®); and behavioral counseling. An updated version of the PHS guideline, released in 2008, also recommends coverage of varenicline tartrate (brand name Chantix®).9, 10

Previous research on the coverage of TDTs has focused on trends in coverage among state Medicaid programs, trends in commercial HMOs, and coverage in employer-sponsored health plans. Coverage for TDTs in Medicaid programs has increased significantly since 1999, when 30 (59%) Medicaid programs reported coverage for TDTs for their general population, compared to 39 (76%) Medicaid programs in 2006.11 Increases in coverage have also been reported nationally among HMOs: The 25% reporting coverage for any TDTs in 1997 increased to 88% in 2003.12

While these data provide some insight into coverage for TDTs, they are not generalizable to the largest insured segment of the population—those with employer-based health insurance coverage. One national study13 of employer coverage for TDTs conducted in 2001 showed low levels of coverage, with 20% of employers reporting that they covered any TDTs and 10% covering both prescription drugs and counseling. Among union workers, it has been reported that 29% of plans offer some coverage for TDTs.14 Higher rates of coverage for TDTs have been reported among state employees; 29 of 45 states report covering at least one TDT, and 17 of 45 states cover both drugs and counseling.15

Previous data published on employer-sponsored coverage for TDTs among California employers indicated that 40% of covered workers in HMOs had coverage for some form of TDT.16 California's comprehensive anti-tobacco campaign has been quite effective, with an estimated 33,000 fewer deaths from heart disease and a significant age-adjusted decrease in lung cancer rates between 1988 and 2002.17, 18, 19 However, there are still almost 4 million smokers in California, the vast majority of whom would like to quit.8, 20 With nearly 14 million adult Californians enrolled in employer-sponsored insurance plans, of whom 12.8%—or nearly 1.8 million—are current smokers, the adoption of coverage for effective tobacco-control treatments in California's employer-sponsored health insurance plans has the potential to reduce both the number of smokers in the state and the adverse health consequences and healthcare costs attributable to smoking.20

This study presents trends in coverage for TDTs in employer-sponsored health insurance coverage. Using surveys of California employers conducted in 2000 and 2005, this research sought (1) to document the current availability, as well as changes in availability, over a 5-year period (2000–2005), of coverage for TDTs under employer-sponsored health insurance, and (2) to analyze the trends by plan type (HMO, preferred provider organization [PPO], or point-of-service plan [POS]); firm size; and industry.

Results 

In 2005, 57% of the workers in firms offering employer-sponsored health insurance coverage were offered benefits that included coverage for at least one form of TDT (Table 1). Specifically, 47% of workers had coverage for NRT, 36% had coverage for Zyban®, and 40% had coverage for smoking-cessation counseling. Twenty-two percent of the workers had coverage for all three types of TDTs.

Table 1. California workers offered coverage for tobacco-dependence treatments (TDTs), 2000 and 2005

		Workers offered TDT
		2000 % (95% CI)	2005 % (95% CI)	p-value
	Any TDT	44.4(38.5,50.5)	57.4(48.9,65.4)	<0.001
	NRT	35.6(29.9,41.6)	46.6(40.2,53.2)	0.003
	Zyban®	16.2(12.5,20.8)	36.2(29.9,43.0)	<0.001
	Counseling	30.3(24.4,36.9)	40.2(31.6,49.4)	0.02
	All	10.7(8.1,14.0)	22.2(16.4,29.4)	0.001

Sources: Kaiser Family Foundation/Health Research and Education Trust California Employer Health Benefits Survey, 2000; California HealthCare Foundation/Center for Studying Health System Change California Employer Health Benefits Survey, 2005 Note: The denominator is workers in firms offering employer-sponsored health insurance coverage. The firm's response is weighted by the number of workers in each firm. On the survey instrument, firms were asked if they provided coverage for behavioral smoking cessation programs, which has been labeled counseling in the table. NRT, nicotine replacement therapy

Increases in coverage were seen across all forms of TDTs from 2000 to 2005. While 44% of workers in firms that offered health insurance coverage had coverage for at least one of the TDTs in 2000, this number increased significantly to 57% of workers in 2005. Similar trends were seen across all forms of TDTs, with the percentage of workers covered for NRT increasing from 36% to 47%, coverage for Zyban® increasing from 16% to 36%, and coverage for counseling increasing from 30% to 40%. The percentages of coverage for all three forms of TDT in employer-sponsored plans doubled over the 5-year time period from 11% to 22%.

Coverage for TDTs in employer-sponsored health plans was also examined by the type of health insurance plan: HMO, PPO, or POS. Although coverage varied across the three plan types (Table 2), with the exception of coverage for all three types of TDTs, the sample sizes were not large enough to detect significant differences. In 2005, coverage for any TDT ranged from 45% of California workers in POS plans with employer-sponsored health insurance to 62% in PPO plans (p=0.08). In addition, coverage for all three TDTs ranged from 15% among workers in HMOs to 31% for workers in PPOs (p=0.03).

Table 2. California workers offered coverage for tobacco-dependence treatments (TDTs), by plan type (HMO, PPO, POS), 2000 and 2005

		2000 % (95% CI)	2005 % (95% CI)	p-value
	HMO coverage
	Any TDT	48.8(40.2,57.6)	58.5(47.2,68.9)	0.090
	NRT	38.9(29.9,48.7)	43.0(34.4,52.0)	0.43
	Zyban®	14.8(10.6,20.3)	30.4(22.3,39.8)	<0.001
	Counseling	36.3(26.6,47.2)	39.1(28.1,51.3)	0.68
	All three TDTs	12.0(8.0,17.6)	14.8(10.1,21.1)	0.35
	PPO coverage
	Any TDT	43.3(36.2,50.8)	61.9(52.0,70.9)	0.002
	NRT	32.5(26.4,39.3)	55.4(45.1,65.3)	<0.001
	Zyban®	23.4(16.4,32.3)	44.1(33.0,55.9)	0.004
	Counseling	28.9(22.1,36.8)	42.9(32.4,54.2)	0.030
	All three TDTs	11.5(8.0,16.2)	30.6(18.8,45.8)	0.002
	POS coverage
	Any TDT	33.5(23.0,45.9)	44.9(33.4,56.9)	0.22
	NRT	30.7(20.5,43.1)	38.8(27.4,51.5)	0.38
	Zyban®	9.5(5.2,16.8)	36.6(25.5,49.2)	<0.001
	Counseling	15.5(10.7,21.9)	37.6(26.1,50.7)	0.002
	All three TDTs	5.8(3.0,11.1)	26.0(15.4,40.4)	<0.001

Sources: Kaiser Family Foundation/Health Research and Education Trust California Employer Health Benefits Survey, 2000; California HealthCare Foundation/Center for Studying Health System Change California Employer Health Benefits Survey, 2005 Note: The denominator is workers in firms offering employer-sponsored health insurance coverage. The firm's response is weighted by the number of workers in each plan type. On the survey instrument, firms were asked if they provided coverage for behavioral smoking cessation programs, which has been labeled counseling in the table. NRT, nicotine replacement therapy; POS, point-of-service; PPO, preferred provider organization

When trends in coverage by plan type were observed, there were significant increases in coverage from 2000 to 2005 for workers in POS and PPO plans. Among workers in POS plans, coverage for TDTs increased significantly for Zyban® (10% to 37%); counseling (16% to 38%); and coverage for all three TDTs (6% to 26%). Workers in PPOs saw the greatest changes, as coverage increased across every type of treatment, and the percentage of coverage for all three TDTs almost tripled (12% to 31%). Among workers in HMOs, the only significant increase from 2000 to 2005 was in coverage for Zyban® (from 15% to 30%).

Table 3 presents 2005 coverage data weighted by the number of firms and broken out by firm size. This table shows that there were significant differences in coverage for TDTs by firm size; the larger the firm, the more likely it was to cover TDTs. Among firms offering health insurance coverage, small firms had the lowest rates of coverage for any TDTs, Zyban®, and behavioral treatments. In addition, the largest firms (those with ≥1000 workers) had the highest rates of coverage for TDTs.

Table 3. California firms offering coverage for tobacco-dependence treatments (TDTs), 2005 (%)

		Any TDT	NRT	Zyban®	Counseling	All
	All firms	44.6	39.6	23.1	29.5	14.9
	By size
	3–49 workers	42.6	38.7	21.0	27.6	13.9
	50–199 workers	57.3	42.6	37.1	43.0	20.9
	200–999	53.1	45.9	32.7	36.0	20.7
	1000+	67.8	58.5	43.7	47.8	28.3
	F1,55 (p-value)	4.1(0.03)	1.5(0.24)	4.4(0.03)	5.8(0.009)	2.4(0.12)

Source: California HealthCare Foundation/Center for Studying Health System Change California Employer Health Benefits Survey, 2005 Note: The denominator is firms offering employer-sponsored health insurance coverage. On the survey instrument, firms were asked if they provided coverage for behavioral smoking cessation programs, which has been labeled counseling in the table. NRT, nicotine replacement therapy

Over time, significant increases in the coverage of TDTs were observed, primarily in mid-size and large firms. In mid-size firms with 50–199 workers, coverage offering any TDTs increased from 45% to 57%; coverage for Zyban® increased from 19% to 37%; and coverage offering all three forms of TDT increased from 13% to 21% (data not shown). In firms with ≥1000 workers, coverage for Zyban® increased from 23% to 44%, and coverage for all three forms of TDT increased from 13% to 28% (data not shown).

Analyses also were run to estimate the differences in coverage for TDTs among employers in different industries. No significant differences were found in the rates at which firms in manufacturing, transportation, utilities, and communications; high technology, health care, and finance; retail and wholesale; service; and mining, agriculture, and construction industries offered coverage for TDTs in 2005 (data not shown). Overall, the only significant increase in coverage rates from 2000 to 2005 was observed among retail and wholesale firms, where coverage increased from 37% to 58% of the firms (data not shown).

Discussion 

Overall, among the private firms in California that offer health insurance coverage to their workers, there was a significant increase from 2000 to 2005 in the percentage of workers (44% to 57%) covered for at least one type of TDT. This corresponds to 38% of private firms offering coverage in 2000 compared to 45% offering coverage in 2005. There are a couple of factors that may have contributed to this increase in coverage. A clinical practice guideline published in 2000 by the PHS recommended that all health insurers cover TDTs.8 In addition, in 2001, the results of an RCT on the effectiveness of coverage for NRT and group counseling conducted at two large HMOs in California was published22; based on the positive results, both of the participating HMOs began covering TDTs in the policies they offered for group covereage. All of this suggests that the environment surrounding and the information available to inform the benefit decisions of California firms may have increased the rates at which they cover TDTs in their employer-sponsored health plans.

Despite these gains, only 22% of workers in private employer–sponsored plans had coverage for all three types of TDTs in 2005 as recommended in both the 2000 and 2008 PHS guidelines. This is particularly significant in light of new evidence presented in the 2008 guideline that certain combinations of TDTs are more effective compared to single treatments alone.9, 10 In addition, both guidelines recommend tailoring treatment to the individual needs of each smoker, which is dependent on the variety of treatment options available. While the trends found in this research are encouraging, they still fall short of the recommendations made in the PHS guidelines, as well as the Healthy People 2010 objectives, in which the target is 100% insurance coverage of evidence-based treatment for nicotine dependency.23

In 2005, an attempt was made to legislate a mandate for 100% insurance coverage for TDTs in California with the introduction of SB 576.24 This bill would have required all HMOs and health insurance plans covering outpatient prescription drugs to include coverage for tobacco-cessation services that included both counseling and all U.S. Food and Drug Administration–approved medications for smoking cessation in compliance with the 2000 PHS guideline.24 Although the bill was passed by both the California Senate and the Assembly, it was ultimately vetoed by Governor Schwarzenegger, citing an increase in the cost of health insurance coverage as a main concern.25 This was in spite of evidence demonstrating that tobacco interventions are cost-saving and that tobacco cessation reduces both medical costs and productivity loss to employers.3, 4 In addition, a recent study26 of adult Californians with employer-sponsored health insurance indicated that a majority (62%) support a health insurance mandate for coverage of TDTs, while 56% are willing to pay $3 more in annual health insurance premiums to finance such a mandate.

Limitations 

There are three limitations that should be taken into consideration when viewing the results of this research. First, although the survey questions were identical on the 2000 and 2005 surveys, in the event that a respondent asked for more detail regarding any of the three treatments, additional information was provided to surveyors in 2005 that was not available in 2000. Specifically, if respondents asked for additional information on Zyban®, they were told that it is also known as Wellbutrin, which is a pill to help people quit smoking. If they asked what was included in behavioral smoking cessation programs, they were told individual and group counseling with a doctor or health professional trained to help people quit smoking, or proactive telephone counseling. Neither survey instrument addressed the issue of coverage for prescription versus over-the-counter NRTs.

The response rates for the 2000 and 2005 surveys were 41% and 36%, respectively. It is possible that firms that respond to the annual survey are likely to offer more generous benefits than nonrespondents. Although the weighting methodology takes into account differences in the rates of offering health insurance coverage between respondents and nonrespondents, it did not account for potential differences in the scope of coverage (i.e., TDT benefits) between respondents and nonrespondents. Therefore, these results may also over-represent the level of coverage of TDTs in employer-sponsored health plans.

Finally, the results from the survey may not be generalizable to other states or to the country as a whole. The tobacco-control movement in California has been comprehensive and effective in spreading the message about the harms of tobacco use and the benefits of quitting.17 In addition, California is one of five states that require both counseling and medication (prescription and over-the-counter) TDT coverage for state employees as well as coverage for NRT, bupropion SR, and counseling for Medicaid enrollees.11, 15 This suggests that employers in California are operating in an environment that may exert stronger pressure to offer coverage for TDTs. Therefore, it is possible that firms in California are more likely to offer coverage for TDTs than firms in other states. However, California is considered a health insurance market bellwether, so it is possible that trends in California provide a glimpse of the future of employer coverage for TDTs across the nation.27

Conclusion 

Tobacco use places a considerable burden on the healthcare system in California and takes a heavy toll on the public's health.28 Approximately one half of adult Californians receive their health insurance through their employer.20 Thus, to the extent that public policy can be an effective tool in influencing health insurance coverage, policies directed at the commercial group health insurance market are most likely to produce impacts for the largest number of Californians. Given the effectiveness, cost effectiveness, and relatively low cost of covering TDTs—estimated to be $3–$6 per member per year—it is difficult to understand why such coverage is not more widely available in California.29, 30, 31, 32 Given the public support in California for mandating health insurance coverage for treating tobacco dependence, it is likely that another mandate bill will be introduced into the state legislature in the future.