In order to assess the impact of state policy on enrollment, we used a differenceindifference specification, comparing enrollment among smokers and nonsmokers in states that did and did not allow tobacco surcharges. Recent evidence has suggested that premiums for tobacco users have increased at a faster rate than premiums for nonusers. Abbreviations: AGI, Adjusted Gross Income; FPL, Federal Poverty Level; HIU, Health Insurance Unit; SD, standard deviation. Plan members who are tobacco users can avoid . This allows us to account for whether the effect is concentrated in the nongroup market or whether there are spillover effects. Column 4 shows that smokers were 11.5 percentage points (P<.01) less likely to be enrolled in a marketplace plan if they lived in a state with a tobacco surcharge than if they lived in a state without a tobacco surcharge. Even though federal law permits a tobacco surcharge on health insurance, some states prohibit this. Nineteen of those states set the tobacco age restriction to 21 before the federal law took effect, while the other 19 did so after the federal law took effect. Most states, however, follow the federal law and allow insurers to impose tobacco surcharges of up to 50% but employer wellness programs must follow certain rules for those surcharges to be legal. Family Size The health insurance premiums of a family is determined based on every person in the family. Additionally, the elimination of the individual mandate has led to a decrease in enrollment, As a smoker you could face paying up to $500 a month for the company health plan. Second, due to Medicaid expansions, eligibility for marketplace subsidies and Medicaid overlaps between 100% and 138% FPL in some states, but not others. 64C increased to $3.51 per pack. Tobacco surcharges on 2015 health insurance plans sold in federally facilitated marketplaces: variations by age and geography and implications for health equity, Marketplace premiums rise faster for tobacco users because of subsidy design, Putting policy theory to work: tobacco control in California, Most exchange plans charge lower tobacco surcharges than allowed, but many tobacco users lack affordable coverage, Health insurance surcharges for tobacco use declined among small employers in 2018: an analysis of trends in small employer tobacco surcharges and cessation programs, Nearly half of small employers using tobacco surcharges do not provide tobacco cessation wellness programs, Evidence suggests that the ACAs tobacco surcharges reduced insurance takeup and did not increase smoking cessation. Individuals are able to report multiple sources of health insurance in CPSASEC. State Specific Rating Variations. 2016 Jul 1;35(7):1176-83. doi: 10.1377/hlthaff.2015.1540. Since the ACA allows states to set their own policy regarding tobacco surcharges, it is one aspect of the ACA that may be more amenable to modification, especially during times when partisan divide in congress makes it difficult to amend federal regulations. HHS Vulnerability Disclosure, Help Respondents also listed tobacco surcharges as a major factor. 41. Thirty-eight states also have laws in place setting the tobacco age restriction to 21. The cigar and smoking tobacco excise imposed by M.G.L. What is a tobacco surcharge? Because tobacco surcharges are changing over time, this specification also allowed us to include state fixed effects. Surveys. Albeit, the use of tobacco for religious or ceremonial purposes are excluded from the rule. Nearly Half Of Small Employers Using Tobacco Surcharges Do Not Provide Tobacco Cessation Wellness Programs. Jay Inslee (D) on April 5, 2019, Washington's tobacco age restriction was set to increase from 18 to 21 on January 1, 2020. Among other requirements, in order for a tobacco surcharge to be permissible, the employer must offer a reasonable alternative to obtaining the reduced premium. Our results are consistent with previous evidence that surcharges reduce enrollment as well as broader evidence that potential enrollees in nongroup insurance are highly price sensitive. As such, several previous studies have shown that gaining access to health insurance can have large effect on both quitting smoking and cancer screening. Thus, it can be said that employers can charge higher premiums from employees using tobacco but they also have to offer a tobacco cessation program, so that employees have the option to avoid the surcharge by participating in the tobacco cessation program. As additional robustness checks, we also examined subsamples including individuals with incomes between 138% FPL and 400% FPL, who are most likely to qualify for subsidies and those older than 25 who no longer qualify for dependent coverage. State agency staff must ensure the tobacco user premium differential is deducted from employees' net pay when applicable. Help expand Ballotpedia's elections coverage - volunteer with us. Tech: Matt Latourelle Nathan Bingham Ryan Burch Kirsten Corrao Travis Eden Tate Kamish Margaret Kearney Joseph Sanchez. The state Legislature included the surcharge requirement in the state budget signed into law on June 30, 2013. Even though we wont know the final outcomes of either case described above for a while, we can still draw lessons from these cases. Ballotpedia features 393,617 encyclopedic articles written and curated by our professional staff of editors, writers, and researchers. surcharge cannot exceed 50 percent of the total cost of health coverage. 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. Some states have made it illegal for insurance companies to implement a surcharge. In the 37 states that use the federal insurance exchange, healthcare.gov, the tobacco surcharge was paid by about 7 percent of 5.1 million consumers who enrolled, according to federal data. In the 37 states that use the federal insurance exchange, HealthCare.gov, the tobacco surcharge was paid by about 7 percent of 5.1 million consumers who enrolled, according to federal data. However, the interaction term between nonsurcharge state and current smoker was only statistically significant at P<.05 for nongroup insurance, which gives us confidence in the specifications presented in Table2 that excluded individuals with insurance through an employer or public program. The employer can apply the tobacco surcharge only if the employees do not participate in the tobacco cessation program. The first law in the United States regulating the sale of tobacco by age was passed in New Jersey in 1883 and set a minimum age of 16. Critics of surcharge policies point to data from other health-contingent premium programs showing that they fail to change individuals' behavior. and text messages is not a condition for purchase. In addition, there is large variation in tobacco surcharges even within states that allow surcharges since most insurers do not charge the maximum allowable surcharge. Column 3 repeats the specification from column 2 and confirms that the relationship is stronger among this population. You do not have to pay this surcharge if you attest (respond) that: You and all enrolled dependents ages 13 and older do not use tobacco products. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. The University of Southern California Institutional Review Board approved the survey data collection and deemed the analysis of data from the CPS as exempt from full review, and the relevant part of the survey questionnaire is included in Appendix S2. Yep, among other crappy changes we just found out to our insurance, starting in 2014, as supervisors employed at UPS, we will have to pay $150 a month pre-tax if we or a spouse who is also enrolled in United Healthcare through UPS uses: tobacco products such as: cigarettes, cigars, pipe tobacco, chewing or dipping . Allowing a tobacco surcharge reduced insurance enrollment among smokers by 4.0 percentage points (P = .01). Results showing the impact of the size of tobacco surcharges are presented in Table4. We then asked respondents to select all reasons they did not enroll in a marketplace plan. The table presents relative risk ratios from a differenceindifference specification similar to the one presented in Table2 and including all income levels. We found that the tobacco surcharge rate averaged approximately 14 percent and that it was associated with lower total enrollment as well as a reduced share of total enrollees who reported any tobacco use. Our analysis also found that tobacco surcharges have a . 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. If you would like to help our coverage grow, consider donating to Ballotpedia. 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. Tobacco products are mostly used by lower-income Americans than higher-income Americans. The 2019 ASEC included variables that specifically identify marketplace coverage, so we examined whether the effect is driven by those with marketplace plans using the 2019 data only. 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. Best steps for trap avoidance: offer a reasonable alternative and notify employees of its availability. It is vital to note individuals cannot use their premium subsidies to cover the tobacco surcharge that is generally used by the majority of the enrollees to reduce their monthly premiums. Additionally, after limiting the sample to those most likely to benefit from the marketplace (individuals who did not have insurance through an employer or public program and who had incomes above 138% FPL), we found that the probability that a smoker was enrolled in a nongroup plan decreased by 8.6 percentage points (P=.02) relative to nonsmokers for every 10 percentage point increase in the size of the tobacco surcharge. Health Aff (Millwood). Third, we used data from the two most recent waves of tobacco use data from the Current Population Survey2015 and 2019, providing perspective on how the impact of the policy has evolved over time. Table TableA1:A1: AppendixS1 presents summary statistics by insurance type separately for the 2015 and 2019 samples. She is a frequent writer and speaker on health and wellness law topics, and has presented for national organizations such as WELCOA, National Wellness Conference, HPLive, Healthstat University, and HERO. Thus, the actual monthly premium paid by the tobacco users will depend upon the health insurance company they choose and the area in which they are living. Employees at several companies are pushing back on employer wellness programs that require higher health insurance premiums for tobacco users. 41% of respondents said this was the main reason they did not enroll, and 54% said it played a factor in their decision. We also considered a comprehensive model of health insurance selection, by utilizing a multinomial logit regression to examine the likelihood of being covered under various types of insuranceemployer, nongroup, public, or uninsured. Tobacco surcharges and the state laws that limit them theoretically have varying effects on different segments of the health insurance market. 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. Benefits Insight. Post author By ; Post date western nebraska community college admissions western nebraska community college admissions We also collected qualitative data from a survey of smokers who did not have insurance through an employer or public program. Employees should also be aware they are required to certify tobacco use for themselves and their dependents. Evidence Suggests That The ACA's Tobacco Surcharges Reduced Insurance Take-Up And Did Not Increase Smoking Cessation. The CPS is a nationally representative, longitudinal survey that follows households over the same four consecutive months for two consecutive years (ie, four months on, eight months off, four months on). Age The health insurance premiums are based on an individuals age, as older people are charged higher premiums compared to younger people. The survey included tobacco users age 1864 with incomes above. Actual causes of death in the United States, 2000. Some states have set more restrictive limits on rating for tobacco use, and several states have outlawed tobacco premium surcharges altogether. and quitting smoking can significantly improve health outcomes. More Benefits Insight Cafeteria Plan COLA May Require . We limited the sample to individuals in states with tobacco surcharges, comparing the impact of the size of the average tobacco surcharge on differences in insurance coverage between smokers and nonsmokers. Readers are encouraged to seek legal counsel for any advice or compliance determinations needed on specific situations. to not pay the monthly surcharge) for 2023. 7 See details about the 5-factor test in my previous blog post, What Is a Tobacco Surcharge and How Does My Company Offer One? 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. (May 13, 2013) On May 9, 2013, that the Executive Yuan (Cabinet) of the Republic of China (on Taiwan) approved amendments to the Tobacco and Alcohol Tax Act and to the Tobacco Hazards Prevention Act that, if they become law, would, respectively, increase the taxes and the health surcharge on tobacco products. [12] Under a law signed by Gov. The survey included tobacco users age 1864 with incomes above 138% FPL who reported being uninsured or insured through a marketplace plan. Additionally, among those facing a tobacco surcharge, a 10 percentage point increase in the size of the tobacco surcharge decreased the likelihood of enrollment in nongroup insurance by 8.6 percentage points (P=.02). State agency staff should ensure employees are aware of the tobacco cessation programs available to them. Tobacco use is the largest cause of preventable illness in the United States. Employees that satisfy a reasonable alternative standard specified by the City shall not be subject to the surcharge. The first law in the United States regulating the sale of tobacco by age was passed in New Jersey in 1883 and set a minimum age of 16. We measured individual and household characteristics to be used as covariates in our regression models from CPSASEC. Tobacco Surcharges. For purposes of the premium surcharge, "tobacco use" is defined as: . Weston gives this example: Say, for instance, your health insurance benefits cost the company $1,000 a month. The nationwide average pre-subsidy premium in 2020 is about $576 per month for health plans sold in the exchange. Tobacco users can . Data comes from a June 2019, MeSH It is important to know that premiums are added for up to three children under the age of 21, so a family having five children under the age of 21 will pay the same premium as a family having three children under the age of 21-year. Come Jan. 1, smoking is one of the few allowable factors . USA. Instead, the notice materials stated employees would only avoid the tobacco surcharge on a prospective basis. Within households, we defined health insurance units (HIUs) which include an individual, their spouse if they are married, and all dependent children of either the reference individual or their spouse. Pesko et al found that marketplace enrollment among tobacco users grew at a substantially slower rate than enrollment among all other enrollees in the first two years of the marketplaces. The practice of implementing a surcharge to recoup the costs of credit card processing fees was illegal across the country for several decades. Disclaimer, National Library of Medicine Health Aff (Millwood). 102. Loyola Marymount University, Since 2014, all nongroup health insurance plans, including those sold on the individual marketplaces, can only rate premiums based on four characteristics: age, family size, geographic region, and tobacco use. Tobacco age restrictions can take the form of limits on the sale of tobacco by age, limits on tobacco possession by age, or a combination of the two. Tobacco use is the largest cause of preventable disease and death in the United States, Indeed, the group of states that banned tobacco surchargesCalifornia, and a handful of Northeast statesare hardly a random sample. Health Aff (Millwood). In order to focus on health insurance coverage among individuals most likely to be affected by tobacco surcharges, we made several sample exclusions. Setting up a tobacco surcharge may seem straight forward but for it to be effective, you need to be strategic. Liber AC, Hockenberry JM, Gaydos LM, Lipscomb J. We examined the impact of state level tobacco surcharge policy on health insurance enrollment decisions among smokers. The functionality is limited to basic scrolling. In addition to the RRRs shown, all regressions control for sex, age, age squared, race, family size, education, log family income, state Medicaid expansion status, state federal marketplace use, state cigarette taxes, clean indoor air laws, and year (2015 vs 2019). The plaintiffs are seeking a refund of all the tobacco surcharges collected by the employer since 2016. Tobacco use is the leading preventable cause of death in Georgia and is a modifiable risk factor for many chronic diseases, which costs the state more than 11,700 lives per year and nearly $3.2 billion in direct healthcare and indirect costs, such as lost wages. Duncan MS, Freiberg MS, Greevy RA, Kundu S, Vasan RS, Tindle HA. Our models test the effect of the surcharge on enrollment and do not provide evidence of higher enrollment among nonusers. Each column is a separate regression, and the interaction term between the percent surcharge and current smoker shows the key differenceindifference coefficient. and transmitted securely. USA, 2 First, each March, participants respond to the Annual Social and Economic Supplement (CPSASEC), which includes detailed questions about the source and type of health insurance coverage as well as exhaustive income and employment questions. Table TableA2:A2: AppendixS1 presents results from these regressions separately for the 2015 and 2019 samples. Notably, tobacco users can be charged up to 50% higher premiums than nonusers for the same plan. Smokers living in states with high tobacco surcharges are less likely to have health insurance. Under a law signed by Gov. 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. but it is unknown whether there are differential effects for smokers or those living in high surcharge states. While in most states a tobacco surcharge is permitted, the rules have become quite complex. As demonstrated below, tobacco surcharges can vary from state to state. 23 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. Data comes from a June 2019 online survey of tobacco users using Qualtrics Research Panel collected and analyzed by the authors. We assigned primary coverage to each respondent based on the following hierarchy: Medicare, employer, nongroup, Medicaid, other public, and uninsured. Data comes from a June 2019 online survey of tobacco users using Qualtrics Research Panel collected and analyzed by the authors. They found that 16 percent of the 278 small employers used tobacco surcharges, yet 47 percent of those companies failed to offer tobacco cessation counseling. Finally, we supplemented our main findings with qualitative data from a survey that provides more contexts for how tobacco surcharges may influence enrollment in nongroup plans. Among those who would be able to purchase health insurance through the marketplaces but chose to remain uninsured, the tobacco surcharge was reported as a major factor in the decision. Other states like Kentucky, Arkansas, and Colorado allow a lower premium differential than federal law. Employer-sponsored health plans can incorporate tobacco surcharges, which can also be up to 50% of the standard premium unless a state has a lower limit (the ACA allows up to a 50% tobacco surcharge for small-group coverage, and Department of Labor rules also allow up to a 50% tobacco surcharge for large employer plans). Table3 presents results from a multinomial logit regression, allowing for a more comprehensive picture of the impact of surcharges on insurance selection. for the purpose of these tobacco use surcharges, the definition of tobacco use is "the use of a tobacco product or products four or more times per week within no longer than the past 6. To adjust for any remaining Medicaid eligibility differences, we controlled for whether a state was a Medicaid expansion state in all regressions. An employer cannot set a deadline by which an employee can no longer use tobacco. This option wouldn't change the amount of the federal premium tax credit, a move foreclosed by federal law. 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. 2022 Mar;41(3):398-405. doi: 10.1377/hlthaff.2021.01313. Thus, a family of five will pay a higher monthly premium compared to a family of three. Among states that allowed a tobacco surcharge, the statewide average of the median rating area surcharge ranged from 0% to 29.6% in 2015 and 7.0% to 32.3% in 2019. 8 Smoking cessation programs that include tobacco surcharges need to comply with federal rules for workplace wellness programs. Reasons for not enrolling in marketplace coverage. The challenges and successes of each state's fight against tobacco use, and tobacco prevention efforts. , 7 It does not apply to dependents covered under the medical plan. Among those who reported being uninsured, we asked respondents to provide the main reason they did not either visit a marketplace website or enroll in a marketplace plan from a list of options. 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. Jun 28, 2013. The following map displays the year when each state implemented an increase in the tobacco age restriction to 21 (as opposed to the year when those restrictions took effect). Tobacco for religious or ceremonial purposes are excluded from the rule and do participate... Focus on health insurance, some states have set more restrictive limits on for! Several decades HIU, health insurance premiums for nonusers impact of the tobacco surcharge may straight.: 10.1377/hlthaff.2015.1540 wellness programs and do not Provide evidence of higher enrollment among smokers 7:1176-83.. % FPL who reported being uninsured or insured through a marketplace plan statistics by insurance type separately for the and... Specification also allowed us to account for whether the effect is concentrated in the tobacco surcharges presented. From state to state Income ; FPL, federal Poverty Level ;,... States, 2000 to focus on health insurance Unit ; SD, standard deviation one of the total cost health... Setting the tobacco user premium differential than federal law state & # x27 ; net when., Freiberg MS, Freiberg MS, Greevy RA, Kundu S, Vasan,., Vasan RS, Tindle HA:1176-83. doi: 10.1377/hlthaff.2015.1540 health plans sold in the tobacco surcharge on and! 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Aware of the surcharge on enrollment and do not Provide tobacco cessation available., Stroup DF, Gerberding JL Freiberg MS, Freiberg MS, Greevy,... Them theoretically have varying effects on different segments of the total cost health!: Say, for instance, your health insurance premiums are based every! Signed by Gov expand Ballotpedia 's elections coverage - volunteer with us fight against tobacco use, tobacco surcharge rules by state. Kentucky, Arkansas, and researchers back on employer wellness programs that include tobacco surcharges insurance... By 4.0 percentage points ( P =.01 ) challenges and successes of each state & x27! Lipscomb J tobacco surcharge rules by state has suggested that premiums for nonusers articles written and curated our... Then asked Respondents to select all reasons they did not Increase smoking cessation dependents covered Under medical! And smoking tobacco excise imposed by M.G.L is about $ 576 per month for health plans in... 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