Health care reform legislation has significant implications for access to services and expansion of benefits for smokers in California, a population with elevated medical and psychiatric comorbidities and high healthcare costs. Key provisions of the Affordable Care Act (ACA) that took effect in 2014 have expanded access to previously uninsured populations in California. The greatest gains in coverage have been seen among young adults, men, Latinos, and low-income enrollees, groups that are disproportionately represented among California’s smokers. The ACA requires comprehensive coverage for tobacco treatment and has the potential to connect these vulnerable groups of newly insured smokers with effective tobacco cessation services. However, the health impact will depend on the extent to which these services are used. The overarching, long-term goal of this study is to examine the impact of this landmark health care legislation on the composition and treatment needs of newly-enrolled smokers in Kaiser Permanente Northern California’s (KPNC) large, integrated health care delivery system, and to inform health policy on best strategies for meeting these needs.
The study utilizes a robust, established electronic health record (EHR), which has become increasingly widespread through federal policy, making it both timely and generalizable. Using the EHR, we will create two cohorts of new members who enrolled in KPNC in 2014 following ACA implementation: 1) “ACA”, new members enrolled in California Exchanges or in Medicaid, and 2) “non-ACA”, traditional new members enrolled in commercial or individual plans not through the CA Exchanges. We will compare these groups on smoking prevalence and characteristics of smokers (e.g., race/ethnicity, age, comorbidities). We will follow ACA and non-ACA smokers up to two years to examine differences in tobacco treatment utilization (individual and group therapy, phone coaching, pharmacotherapy), and to test whether any differences in utilization are explained by patient characteristics or sensitivity to cost sharing. In an innovative mixed-methods approach, we will augment EHR data through interviews with key subgroups of smokers to assess barriers to utilization from the perspective of the target population. Results will provide critical data to assist policymakers and health systems in understanding early barriers to utilization of tobacco treatment. Findings can be leveraged to develop outreach and interventions based on patient characteristics to maximally reach the influx of newly insured smokers as the ACA unfolds.