Low-Income Smokers May Not Be Able to Afford Health Insurance Coverage in the Marketplace

A new study shows just how tough it can be for low-income smokers in the United States to get adequate, affordable health insurance coverage.

In an analysis looking at the plans offered in the Affordable Care Act marketplace, in a state that did not expand Medicaid coverage, Washington University School of Medicine researchers found that some smokers would need to pay more than they actually earned in a year for health insurance.

Smokers face significant challenges when it comes to purchasing health insurance. Insurers are allowed to charge smokers up to 50 percent higher premiums. This surcharge is not offset by premium subsidies that help make coverage affordable for those at low incomes, below 400 percent of the federal poverty level.

In addition, in states that did not expand Medicaid, low-income smokers (below 100 percent of the federal poverty level), eligible for Medicaid in other states, would have to pay full price for health insurance plans in the marketplace -- plus the additional smoking surcharge.

The high cost of plans can keep smokers from purchasing insurance. Yet smokers often have health needs from conditions such as chronic bronchitis, emphysema, and asthma. They use more health care and take more medications than non-smokers. So, while they often need more health care, insurance is often unaffordable.

Researchers Denise Monti and Marie Kuzemchak, led by Mary Politi, studied the intended ACA insurance marketplace choices of 327 people in a state without Medicaid expansion. About a third of people in the study were either smokers or lived with a smoker who would be covered under a plan. Fifty-eight percent of the smokers, and 46 percent of non-smokers had incomes below the federal poverty line - around $12,000 per year for an individual or $24,000 for a family of four.

What they found was that smokers overall in this group would have to spend an average of 14 percent of their annual income on their preferred insurance plans, whereas non-smokers would have to spend just half that - around 7 percent.

Rates, though, varied vastly depending on income. Smokers with incomes above the poverty line would have to spend around 5 - 9 percent of their annual income on premiums for their preferred plans. Those below the poverty line, however, would have to spend 165 percent of their annual income on premiums - more than they actually earn each year. Someone making $5,000 per year, for example, might need to pay $8,250 in premiums annually to be covered.

Rates for non-smokers were generally lower across the board. Non-smokers earning below the poverty line would have had to pay 60 percent of annual income on premiums for coverage for their preferred plans - a prohibitive amount but around two-thirds lower than that for smokers in the same category.

The premiums are even higher for very low-income smokers if they want plans that provide coverage that best meets their health care needs. Because smokers typically have more chronic health conditions than non-smokers, plans that have higher premiums might provide more affordable coverage than plans with lower premiums that often require more out-of-pocket costs for care throughout the year.

Annual premiums for smokers for plans that provide the lowest overall costs each year were an average of 167 percent of their annual income for those below the poverty line, and 3 - 7 percent for those above it.

What these numbers show is that a group already at risk because of income and health status is compromised even further by the inability to afford care. This care can not only help them manage and treat chronic conditions, but also provide resources to help them quit smoking.

One way to alleviate the health insurance burden on smokers - especially low-income smokers - is to do away with premium surcharges. Rather than providing an incentive for smokers to quit smoking (so they can get a lower rate), surcharges may simply make plans unaffordable. And this can take a toll on individuals and their families as well as impose a burden on society to cover the costs of their care.

As the researchers conclude:

"Smokers may forgo health insurance due to the exorbitant costs that are not subject to subsidies for those of low-income. This places an untenable burden on smokers to cover the cost of potentially frequent health care needs. It also leaves other taxpayers and the health care system to bear the health care costs (e.g., procedures, medications, emergency room visits) of smokers who are uninsured. If insured by a marketplace plan, smokers would pay for at least a portion of this care themselves; if uninsured, they would be unlikely to do so. It is more beneficial, both for the health and wellness of the smoker and for the health care system, for smokers to be supported in the process of quitting smoking through coverage of tobacco cessation programs and products…Health insurance costs should not be structured in a way that makes insurance unattainable for smokers."

Smoking remains the single biggest burden on health to individuals and society. To make meaningful strides against smoking, it's important that we make it possible for all smokers to get both the health coverage that meets their needs and the support they need to quit smoking for good.

As this new study shows, we are still falling short.

Photo: Cigarette by AJTiner (CC License, CC BY 2.0)

Making Strides Against Cervical Cancer While Reducing Burden - HPV Vaccination and HPV Testing

By Sydney Philpott

Human papillomavirus (HPV) is a very common sexually transmitted infection. According to the World Health Organization (WHO), most sexually active women and men will have an HPV infection at some point in their lives. While HPV infections usually go away on their own, certain types persist and then serve as the primary cause of cervical cancer. Globally, HPV leads to about 600,000 new cases of cervical and genitourinary cancer each year, with about 26,900 cases in the United States alone.

In 2006, HPV vaccination became available worldwide and was recommended by the WHO and the Centers for Disease Control and Prevention (CDC) for girls age 9-26 and recommended for boys of the same age group in 2011. After just 5-6 years, studies in the United States found that HPV infections in girls age 14-19 dropped 64 percent, risk of cervical pre-cancer was lowered by 47 percent, and there was a 61 percent reduction in treatment for genital warts (infographic). The WHO estimates that two-thirds of new cases of cervical cancer could be prevented if 80 percent of those age-eligible were vaccinated worldwide.

Despite these improvements, vaccination rates in the United States have remained low. On average, only 60 percent of girls age 13-17 initiate the HPV vaccination series and 39.7 percent receive all three recommended doses, while only 41.7 percent of boys initiate and 21.6 percent complete the series. Additionally, there are clear racial and socioeconomic disparities for vaccination in the United States – but these often move in a direction opposite from many health behaviors. Among adolescent girls age 13-17 in 2014, 66 percent of blacks and Hispanics had at least one dose of the HPV vaccine, while 56 percent of whites did. Similarly, 67 percent of those below the poverty line started the series, while only 58 percent above did.

These numbers, though, change a bit when looking at the percentage of girls completing the full three-dose series once they start it, suggesting that efforts that drive initiation of the vaccine fall off in certain groups when it comes to completing the entire series. Of girls who started the series, 68 percent of those living below the poverty level and 69 percent of those living above went on to complete the 3 doses – nearly identical numbers. Similarly, over 70 percent of Hispanics and whites completed the series once they started, whereas only 62 percent of blacks did.

While the relatively high vaccination initiation rate in African Americans is heartening, it's also important to ensure that as many girls as possible get subsequent doses so they are as protected as possible in the future. Currently, African American women are more likely to be diagnosed with cervical cancer at later disease stages and die at almost twice the rate compared with non-Hispanic white women. Improving rates of HPV vaccination and completion across all groups can help narrow such cancer disparities.

Furthermore, recent systematic reviews examining efforts to increase HPV vaccination use in the U.S. have conflicting conclusions, and the relative success of these interventions fell short of national averages and stated vaccination goals.

Compared to the United States, other countries have had considerably more success achieving high HPV vaccination rates. Through implementation of school-based vaccination programs, Scotland reported 81 percent three-dose vaccination in 2011, England reported 76 percent in 2010 and Australia 73 percent in 2014. In 2013, the United States reported that only 37.6 percent of adolescent girls age 13-17 had all three vaccine doses.

These discrepancies may be due to the three-dose requirement remaining a substantial barrier to successful HPV vaccination in the United States. However, recent evidence indicates that fewer than three doses may be protective. Brotherton et al. found that less than three doses provides some protection against cervical disease in Australian women, even when measured within 5 years in a population including those who were sexually active at the time of vaccination. Therefore, adolescents in the United States, and other regions with low vaccination rates, may benefit from even partial vaccination. Updated recommendations for less than three doses could also lead to reduced costs for developing countries as well as broader uptake and access to vaccination. In the United States, nearly half of girls age 13-17 have received two doses of the HPV vaccine.

The ability to also test women for HPV is changing the approach to screening for cervical cancer, especially as more and more women are being vaccinated against HPV.

Since HPV is the direct cause of nearly all cervical cancers, women who are found to have HPV can be followed more closely to see if they clear the infection, or if they have or develop cancer or pre-cancer.

In the United States, the HPV test is most often recommended along with a standard Pap test in women 30 and older. This is called co-testing. In 2014, however, the FDA approved the stand-alone HPV test as a method of cervical cancer screening, and certain professional organizations now strongly suggest that the HPV test can be used on its own as an effective alternative to standard Pap tests in most women being screened for cervical cancer.

In Australia, the National Cervical Screening Program will implement a switch in 2017 from Pap testing every two years for those age 18-69, to HPV screening alone every five years for those between the ages of 25-74. This screening transition is expected to continue to reduce cervical cancer mortality while vastly reducing the burden on women.

Fewer numbers of doctor visits and stressful, time-consuming follow-ups for positive screening tests will be a major saving for women. Improving our ways of summarizing such benefits of HPV vaccination across life from 18 to 69 could help frame vaccination as a benefit to women far beyond just reducing cervical cancer incidence.

Large-Scale Problem: Obesity Rates Still Increasing in Certain Groups

by Hank Dart

The course of the obesity epidemic in the United States has been so bad for so many years that even minor victories have been cause for celebration. But despite some bright spots in the most recent Centers for Disease Control and Prevention reports on national rates of obesity (on adults, on youth), there's little celebrating going on.  The reason?  Some striking milestones in the rates of obesity in both women and teenagers.

The rate of obesity in US women -- which for most of the past decade rested around 35 percent -- has now surpassed 40 percent -- rising from 35.7 percent in 2005/6 to 40.5 percent in 2013/14, the most recent years for which there are data. And this overall number doesn't tell the complete picture, as the burden of obesity isn't shared equally across all groups.  The rate of obesity is around 38.2 percent in white women, 46.9 percent in Hispanic women, and 57.2 percent in black women.  Asian women have the lowest rate, at around 12.4 percent.

While the numbers in men are concerning as well, they've stabilized somewhat over the past decade, bouncing around the mid-30s, with the most recent report finding that 35 percent of men in the United States are obese. As with women, the numbers for men vary by age, with Asians having the lowest rate (12.6%) and blacks the highest (38%).

The new numbers for youth are not quite as striking - but remain concerning as well.  They show that over the past 25 years the rate of obesity in adolescents and teenagers has nearly doubled -- from 10.5 percent to 20.6 percent -- with the overall rate of obesity in youth ages 2 - 19 years old now at 17 percent, up from 10 percent in 1988.

There are, however, two positive trends in younger kids, with rates of obesity dropping since 2004 in 2 - 5 year olds and leveling off since 2008 in 6 - 11 year olds.

The overall picture of obesity in America, however, can be quite discouraging, even for the optimists who tend to work in public health. The epidemic began over two decades ago, and no efforts so far have been able to make real strides in reversing it. And the health, quality of life, and fiscal implications are enormous.

In a recent Viewpoint in the Journal of the American Medical Association, David Ludwig, MD of Harvard Medical School and the New Balance Foundation Obesity Prevention Center writes that the latest evidence may support predictions that the obesity epidemic and its health consequences may begin to shorten life expectancy in coming generations. While advances in the treatment of obesity-related chronic diseases like heart disease, diabetes, stroke, and cancer have kept mortality rates of these disease relatively stable or on the decline, a new provisional report on death rates suggests that mortality rates may now be increasing for some diseases.  The obesity epidemic could be creating more disease, and more serious disease, that advances in treatment can no longer keep up with.

Making progress against the epidemic is going to be essential if we are to help prevent growing rates of disease in the years and decades ahead.

In addition to bolstering research on the causes and prevention of weight gain, we need to support efforts that help people make and maintain healthy food and activity choices.  As with the fight against tobacco, this means multi-pronged, multi-layered approaches - such as improved food and activity offerings in schools and workplaces, taxes on unhealthy foods, subsides for healthy foods, widespread communication campaigns, and infrastructure that allows people to easily and safely fit activity into their days.  The social, financial, and structural environment that surrounds us is key to making and sustaining healthy behaviors.

Stemming the tied of weight gain in the US will not be easy, but it's essential that as a society we garner the will to put in place a concerted effort that will benefit current and future generations.

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See also:

Other Cancer News in Context posts addressing cancer, chronic disease, and weight.