She is also lead author of the book, Rule the Rules on Workplace Wellness Programs, published by the American Bar Association. Our work extends and builds upon this prior work in the following important ways. Impact of allowing a state surcharge on enrollment in a health insurance planresults from differenceindifference linear probability model. Additionally, increased enrollment in nongroup plans in states that did not allow surcharges was not offset by a decrease in the likelihood of having other types of insurance like employer provided insuranceif anything, employer insurance takeup was higher in states without surcharges. Discrimination under the ADA includes requiring medical examinations and making disability-related inquiries, including medical history inquiries, unless 1 of 2 exceptions applies: (1) such exam or inquiry is job-related and consistent with business necessity; or (2) the medical exam is voluntary and part of an employee health program available at the worksite. 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. 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. Column 2 shows the results for the probability of being in a nongroup plan, when the sample was limited to individuals with nongroup insurance and those who report being uninsured. 
Specifically, our model compares the insurance status of smokers to nonsmokers across states with and without tobacco surcharges. Some call this difference in health insurance premium amounts a premium differential or a tobacco use surcharge.. 1 Although we did not have data from other years, the fact that our results were similar across the two years gives us confidence that pooling the data is a valid approach. Web2 Theoretically, tobacco surcharges could lead to lower premiums for nonusers, which could potentially lead to higher enrollment among that group. Access to insurance and health care may be particularly important for tobacco users because they are at higher risk of developing numerous chronic health conditions and because all health insurance plans are required to provide tobacco cessation as an essential health benefit with no outofpocket costs. More research is needed to test whether tobacco surcharges decrease premiums for nonusers. 
Finally, all models adjusted for year of survey (2015 or 2019). Standard errors, clustered at the state level are shown in parentheses. The outcome variable represents four categories of insurance typeuninsured (omitted), nongroup, employer, and public. In states with surcharges, enrollment among smokers was 3.4 percentage points lower (P<.01) for every 10 percentage point increase in the tobacco surcharge. Maximum non-tobacco and tobacco-related incentives (50%) difference permitted 
This site needs JavaScript to work properly. The DOL alleged that this refusal to refund or credit participants for the tobacco surcharge even if they met a reasonable alternative standard violated the ERISA requirement that the full reward be available to all similarly situated individuals of a wellness program. We hypothesized that there would be lower enrollment among smokers, relative to nonsmokers, in states that allowed tobacco surcharges compared to states that outlawed rating by tobacco use. 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. We found that among individuals without insurance through an employer or public program, living in a surcharge state decreased the probability that a smoker enrolled in a nongroup plan by 0.9.0 percentage points (P<.01). 
WebState 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 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. Macys offered a tobacco cessation program to employees, but the only way to avoid the surcharge was for the employee to declare that all covered members in his or her family remained tobacco free for a period of six consecutive months during the health plan year. That is, it must have a reasonable chance of improving the health of, or preventing disease in, participating individuals, and it should not be overly burdensome. Careers, Unable to load your collection due to an error, GUID:57024003-B728-4156-B6F8-1C7CF1E128C4, GUID:8B1E074E-83F9-4927-82C1-164DFCE3D0D8, GUID:B324CE6B-5446-4427-8631-2DF7A4EC06A9. Finally, we gathered data on tobacco surcharges from the CMS Health Insurance Exchange Public Use Files for 2015 and 2019. All columns are derived from a single multinomial logit regression, and each column presents the relative risk ratios (RRR), comparing the risk of being in the insurance type of interest and being uninsured. If that is how employees feel, they may be compelled to complain to the EEOC that the companys wellness program violates the ADA. 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). Read our simple and effective tips for protecting you and your family from the dangers of air pollution. Tobacco surcharges and the state laws that limit them theoretically have varying effects on different segments of the health insurance market. September 29, 2021. The employer determined tobacco use status through an affidavit completed by each employee covered under the employer group health plan. In the CPSTUS, smoking status was defined based on how frequently individuals report smoking. Thus, perhaps somewhat counterintuitively, eliminating or limiting surcharges could potentially lead to an increase in quitting. Studies have shown that tobacco use is more prevalent among racial/ethnic minorities and economically disadvantaged individuals. Although third parties helped administer the tobacco cessation program for Macys, Macys had ultimate control of the wellness program, including: Because of these alleged violations, the DOL is asking the court for the following relief (in relation to the wellness program violations): Also in November 2021, a federal district court in Missouri certified a class action of 1500 casino workers who alleged, similar to the Macys case, that their employer violated ERISA with its tobacco surcharge. WebMassachusetts has many laws that govern tobacco: Tobacco excise taxes. Other important reasons for not enrolling included not knowing about the marketplaces and/or not knowing how to enroll (19% main reason, 29% a factor), believing they were not eligible (8% main reason, 16% a factor), coverage not meeting needs including provider networks or benefits (3% main reason, 14% a factor), not needing health insurance (8% main reason, 11% a factor), or missing the enrollment period (4% main reason, 8% a factor). 17117 individuals opened the survey, and 1034 qualified for and completed the survey. The participant is not expected to achieve a certain wellness goal, such as losing a certain amount of weight or having a certain blood pressure level. Premium rating rules for nongroup insurance and small group plans (generally plans provided by employers with fewer than 50 employees) are similar. NOTES Respondents were assigned to surcharge levels based on their age group and state, using newly collected information on 2014 tobacco surcharges in their states health insurance exchange. 
Our service is free and we are here to help you. Our contribution is particularly important to state policy makers because they may want to understand the comparative effectiveness of banning tobacco rating versus limiting the size of potential surcharges. The plaintiffs state that the law requires the full reward be available upon completion of the reasonable alternative standard, which means the plaintiffs would be entitled to a refund of the $50/month penalty that they had already paid during that plan year. 7 Health Aff (Millwood). The American Lung Association is a 501(c)(3) charitable organization. **, Founder and President, Center for Health and Wellness Law, LLC. Additionally, the elimination of the individual mandate has led to a decrease in enrollment, 2. The .gov means its official. The Georgia Tobacco Use Prevention Program (GTUPP) has the singular mission of eliminating tobacco use and tobacco-related disparities in Georgia by: Preventing Youth and Young Adults Initiation Promoting Cessation Among Youth and Adults Eliminating Exposure to Secondhand Smoke Monitoring, Surveillance and Evaluation official website and that any information you provide is encrypted 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. 
State fixed effects were included in columns (2) and (4) include state fixed effects; however, they did not substantially affect the results. Careers. Before 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. Each column is a separate regression, and the interaction term between the percent surcharge and current smoker shows the key differenceindifference coefficient. Our approach differs from the tripledifference approach used by Friedman et al, which used pre and postACA implementation as a third difference. Health Aff (Millwood). Notably, using data from the Behavioral Risk Factor Surveillance System, Freidman and colleagues found the probability of having insurance was reduced among smokers in states with high tobacco surcharges relative to states without surcharges. The site is secure. 7 This finding was robust across a variety of specifications. 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. 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. Other states like Kentucky, Arkansas, and Colorado allow a lower premium differential than federal law. This blog post is for informational and educational purposes only. Colorado limits the tobacco surcharge to 15%. Nearly Half Of Small Employers Using Tobacco Surcharges Do Not Provide Tobacco Cessation Wellness Programs. , sharing sensitive information, make sure youre on a federal Additionally, the fact that the inclusion of state fixed effects in our model of the impact of surcharge size produced nearly identical results to the same model without state fixed effects gives us confidence that this identification assumption holds. Join over 700,000 people who receive the latest news about lung health, including COVID-19, research, air quality, inspiring stories and resources. Table3 presents results from a multinomial logit regression, allowing for a more comprehensive picture of the impact of surcharges on insurance selection. For example, tobacco surcharges could lead to less employer coverage as a result of higher premiums for tobacco users in the small group market or if large employers were more likely to charge surcharges in states that allowed them in small group and nongroup markets. 
See tips for managers on removing this stigma in the workplace to help employees quit smoking. Due to a ObamaCare smoking glitch where programmers couldnt get the charge to calculate correctly the tobacco surcharge wasnt implemented until 2015 in many states. Notably, smoking rates were higher among those without health insurance than those with nongroup coverage. Column 1 shows the effect of tobacco surcharges on the differences in insurance rates between smokers and nonsmokers for the full sample of nonelderly adults. Furthermore, since tobacco use is selfreported and not verified, tobacco users may lie about tobacco use to avoid the penalty. These limits may not be binding in all cases, as many plans charge less than the maximum allowed, and there is substantial geographic variation in the amount of the sucharge. We coded respondents as current smokers if they reported now smoking cigarettes either every day or some days. This definition is slightly different from the definition used to apply the tobacco surcharge, which is the use of tobacco products four or more times, on average, per week within the past six months. We used the narrower definition, considering only cigarette smokers because cigarette smokers make up most of the population of every day tobacco users Impact of state surcharge size enrollment in a health insurance planresults from differenceindifference linear probability model. 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. 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 tobaccorelated disease. The ACA divides wellness program activities into 2 groups: participatory and health-contingent. Further, smokers without insurance through an employer or public program were 9.0 percentage points less likely (P<.01) to enroll in a nongroup plan if they were subject to a tobacco surcharge. 20 For the purposes of this study, we limited the sample to uninsured individuals (N=519). We know that compliance issues arise no matter the size of the company and no matter how long a law has been in effect. 2 We then asked respondents to select all reasons they did not enroll in a marketplace plan. We first examined the impact of tobacco surcharges on the likelihood of having any type of health insurance. 
We measured individual and household characteristics to be used as covariates in our regression models from CPSASEC. Our key findings add to the evidence that a changing climate is making it harder to protect human health. Further, smokers without insurance through an employer or public program were 9.0 percentage points less likely (P < .01) to enroll in a nongroup plan if they were subject to a tobacco surcharge. 27 The Affordable Care Act allows insurers to charge up to 50% higher premiums to tobacco users, making tobacco use the only behavioral factor that can be used to rate premiums in the nongroup insurance market. Even though we wont know the final outcomes of either case described above for a while, we can still draw lessons from these cases. 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. 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Specifically, our model compares the insurance status of smokers to nonsmokers across states with and without tobacco surcharges. Some call this difference in health insurance premium amounts a premium differential or a tobacco use surcharge.. 1 Although we did not have data from other years, the fact that our results were similar across the two years gives us confidence that pooling the data is a valid approach. Web2 Theoretically, tobacco surcharges could lead to lower premiums for nonusers, which could potentially lead to higher enrollment among that group. Access to insurance and health care may be particularly important for tobacco users because they are at higher risk of developing numerous chronic health conditions and because all health insurance plans are required to provide tobacco cessation as an essential health benefit with no outofpocket costs. More research is needed to test whether tobacco surcharges decrease premiums for nonusers. Finally, all models adjusted for year of survey (2015 or 2019). Standard errors, clustered at the state level are shown in parentheses. The outcome variable represents four categories of insurance typeuninsured (omitted), nongroup, employer, and public. In states with surcharges, enrollment among smokers was 3.4 percentage points lower (P<.01) for every 10 percentage point increase in the tobacco surcharge. Maximum non-tobacco and tobacco-related incentives (50%) difference permitted This site needs JavaScript to work properly. The DOL alleged that this refusal to refund or credit participants for the tobacco surcharge even if they met a reasonable alternative standard violated the ERISA requirement that the full reward be available to all similarly situated individuals of a wellness program. We hypothesized that there would be lower enrollment among smokers, relative to nonsmokers, in states that allowed tobacco surcharges compared to states that outlawed rating by tobacco use. 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. We found that among individuals without insurance through an employer or public program, living in a surcharge state decreased the probability that a smoker enrolled in a nongroup plan by 0.9.0 percentage points (P<.01). WebState 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 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. Macys offered a tobacco cessation program to employees, but the only way to avoid the surcharge was for the employee to declare that all covered members in his or her family remained tobacco free for a period of six consecutive months during the health plan year. That is, it must have a reasonable chance of improving the health of, or preventing disease in, participating individuals, and it should not be overly burdensome. Careers, Unable to load your collection due to an error, GUID:57024003-B728-4156-B6F8-1C7CF1E128C4, GUID:8B1E074E-83F9-4927-82C1-164DFCE3D0D8, GUID:B324CE6B-5446-4427-8631-2DF7A4EC06A9. Finally, we gathered data on tobacco surcharges from the CMS Health Insurance Exchange Public Use Files for 2015 and 2019. All columns are derived from a single multinomial logit regression, and each column presents the relative risk ratios (RRR), comparing the risk of being in the insurance type of interest and being uninsured. If that is how employees feel, they may be compelled to complain to the EEOC that the companys wellness program violates the ADA. 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). Read our simple and effective tips for protecting you and your family from the dangers of air pollution. Tobacco surcharges and the state laws that limit them theoretically have varying effects on different segments of the health insurance market. September 29, 2021. The employer determined tobacco use status through an affidavit completed by each employee covered under the employer group health plan. In the CPSTUS, smoking status was defined based on how frequently individuals report smoking. Thus, perhaps somewhat counterintuitively, eliminating or limiting surcharges could potentially lead to an increase in quitting. Studies have shown that tobacco use is more prevalent among racial/ethnic minorities and economically disadvantaged individuals. Although third parties helped administer the tobacco cessation program for Macys, Macys had ultimate control of the wellness program, including: Because of these alleged violations, the DOL is asking the court for the following relief (in relation to the wellness program violations): Also in November 2021, a federal district court in Missouri certified a class action of 1500 casino workers who alleged, similar to the Macys case, that their employer violated ERISA with its tobacco surcharge. WebMassachusetts has many laws that govern tobacco: Tobacco excise taxes. Other important reasons for not enrolling included not knowing about the marketplaces and/or not knowing how to enroll (19% main reason, 29% a factor), believing they were not eligible (8% main reason, 16% a factor), coverage not meeting needs including provider networks or benefits (3% main reason, 14% a factor), not needing health insurance (8% main reason, 11% a factor), or missing the enrollment period (4% main reason, 8% a factor). 17117 individuals opened the survey, and 1034 qualified for and completed the survey. The participant is not expected to achieve a certain wellness goal, such as losing a certain amount of weight or having a certain blood pressure level. Premium rating rules for nongroup insurance and small group plans (generally plans provided by employers with fewer than 50 employees) are similar. NOTES Respondents were assigned to surcharge levels based on their age group and state, using newly collected information on 2014 tobacco surcharges in their states health insurance exchange. Our service is free and we are here to help you. Our contribution is particularly important to state policy makers because they may want to understand the comparative effectiveness of banning tobacco rating versus limiting the size of potential surcharges. The plaintiffs state that the law requires the full reward be available upon completion of the reasonable alternative standard, which means the plaintiffs would be entitled to a refund of the $50/month penalty that they had already paid during that plan year. 7 Health Aff (Millwood). The American Lung Association is a 501(c)(3) charitable organization. **, Founder and President, Center for Health and Wellness Law, LLC. Additionally, the elimination of the individual mandate has led to a decrease in enrollment, 2. The .gov means its official. The Georgia Tobacco Use Prevention Program (GTUPP) has the singular mission of eliminating tobacco use and tobacco-related disparities in Georgia by: Preventing Youth and Young Adults Initiation Promoting Cessation Among Youth and Adults Eliminating Exposure to Secondhand Smoke Monitoring, Surveillance and Evaluation official website and that any information you provide is encrypted 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. State fixed effects were included in columns (2) and (4) include state fixed effects; however, they did not substantially affect the results. Careers. Before 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. Each column is a separate regression, and the interaction term between the percent surcharge and current smoker shows the key differenceindifference coefficient. Our approach differs from the tripledifference approach used by Friedman et al, which used pre and postACA implementation as a third difference. Health Aff (Millwood). Notably, using data from the Behavioral Risk Factor Surveillance System, Freidman and colleagues found the probability of having insurance was reduced among smokers in states with high tobacco surcharges relative to states without surcharges. The site is secure. 7 This finding was robust across a variety of specifications. 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. 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. Other states like Kentucky, Arkansas, and Colorado allow a lower premium differential than federal law. This blog post is for informational and educational purposes only. Colorado limits the tobacco surcharge to 15%. Nearly Half Of Small Employers Using Tobacco Surcharges Do Not Provide Tobacco Cessation Wellness Programs. , sharing sensitive information, make sure youre on a federal Additionally, the fact that the inclusion of state fixed effects in our model of the impact of surcharge size produced nearly identical results to the same model without state fixed effects gives us confidence that this identification assumption holds. Join over 700,000 people who receive the latest news about lung health, including COVID-19, research, air quality, inspiring stories and resources. Table3 presents results from a multinomial logit regression, allowing for a more comprehensive picture of the impact of surcharges on insurance selection. For example, tobacco surcharges could lead to less employer coverage as a result of higher premiums for tobacco users in the small group market or if large employers were more likely to charge surcharges in states that allowed them in small group and nongroup markets. See tips for managers on removing this stigma in the workplace to help employees quit smoking. Due to a ObamaCare smoking glitch where programmers couldnt get the charge to calculate correctly the tobacco surcharge wasnt implemented until 2015 in many states. Notably, smoking rates were higher among those without health insurance than those with nongroup coverage. Column 1 shows the effect of tobacco surcharges on the differences in insurance rates between smokers and nonsmokers for the full sample of nonelderly adults. Furthermore, since tobacco use is selfreported and not verified, tobacco users may lie about tobacco use to avoid the penalty. These limits may not be binding in all cases, as many plans charge less than the maximum allowed, and there is substantial geographic variation in the amount of the sucharge. We coded respondents as current smokers if they reported now smoking cigarettes either every day or some days. This definition is slightly different from the definition used to apply the tobacco surcharge, which is the use of tobacco products four or more times, on average, per week within the past six months. We used the narrower definition, considering only cigarette smokers because cigarette smokers make up most of the population of every day tobacco users Impact of state surcharge size enrollment in a health insurance planresults from differenceindifference linear probability model. 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. 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 tobaccorelated disease. The ACA divides wellness program activities into 2 groups: participatory and health-contingent. Further, smokers without insurance through an employer or public program were 9.0 percentage points less likely (P<.01) to enroll in a nongroup plan if they were subject to a tobacco surcharge. 20 For the purposes of this study, we limited the sample to uninsured individuals (N=519). We know that compliance issues arise no matter the size of the company and no matter how long a law has been in effect. 2 We then asked respondents to select all reasons they did not enroll in a marketplace plan. We first examined the impact of tobacco surcharges on the likelihood of having any type of health insurance. We measured individual and household characteristics to be used as covariates in our regression models from CPSASEC. Our key findings add to the evidence that a changing climate is making it harder to protect human health. Further, smokers without insurance through an employer or public program were 9.0 percentage points less likely (P < .01) to enroll in a nongroup plan if they were subject to a tobacco surcharge. 27 The Affordable Care Act allows insurers to charge up to 50% higher premiums to tobacco users, making tobacco use the only behavioral factor that can be used to rate premiums in the nongroup insurance market. Even though we wont know the final outcomes of either case described above for a while, we can still draw lessons from these cases. 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. Like Kentucky, Arkansas, and public Friedman et al, which used and! Having any type of health insurance planresults from differenceindifference linear probability model or limiting surcharges could potentially lead to enrollment. 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