Editor,—In 1997 the National Conference of State Legislatures in the United States conducted a survey of state Medicaid agencies for the Robert Wood Johnson Foundation to determine the extent to which states covered nicotine addiction treatment as a routine benefit under Medicaid (the government programme that provides health care to the poor). Only 22 states and the District of Columbia reported coverage for nicotine addiction treatment services under Medicaid, including only 19 of the 40 states with lawsuits against the tobacco industry to recoup Medicaid costs of smoking. These 22 states were California, Colorado, Delaware, Florida, Louisiana, Maine, Maryland, Michigan, Minnesota, Montana, Nevada, New Hampshire, New Jersey, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Rhode Island, Vermont, and Wisconsin. A repeat survey is now underway to obtain more detailed information on these benefits and to update the findings.1

We estimate that Medicaid provides health insurance coverage for five million or more smokers, including about 70% of all pregnant smokers. Like their counterparts covered under private health insurance, Medicaid smokers need access to readily available, evidence-based nicotine addiction treatment resources and services. Treatment for nicotine addiction is more cost-effective than many other medical interventions that are routinely covered under Medicaid. Brief quit-smoking advice and counselling from a primary-care provider combined with transdermal nicotine are estimated to cost only $263 per successful quitter.2

At the time of the 1997 survey, many states were in the process of moving their Medicaid beneficiaries into fully capitated managed care. Almost half of all Medicaid beneficiaries (47.8%) were in some type of managed care in June 1997—up from 23.1% in 1994.3 This shift to managed care represents a unique “window of opportunity” for states to mandate coverage for tobacco treatment services for their Medicaid enrollees. Contracts negotiated between the State Medicaid agency and private health plans offer an important mechanism for building the assessment and treatment of nicotine dependence into standard basic health care services provided for all Medicaid beneficiaries. In addition, these contracts can establish systems of quality assurance and performance measurement. Such efforts are particularly important because of the high prevalence of smoking among Medicaid beneficiaries, including those enrolled in managed care. A survey of adult Medicaid members of five health maintenance organisations in Michigan showed a smoking prevalence of 44%.4

Therefore, we urge the tobacco control and public health communities to work with their state Medicaid agencies to incorporate explicit language in their managed-care contracts, policy briefs, lawsuit provisions, and Medicaid formularies to ensure nicotine treatment coverage under Medicaid. In states with actual or potential revenues from tobacco excise tax increases or litigation settlements or awards, it is important to seize available opportunities to designate funds to help support Medicaid coverage of tobacco treatments.

At a minimum, the standard benefit for nicotine addiction treatment under Medicaid should cover: (a) health plan or provider payment for “basic” tobacco treatment interventions for all who use tobacco products, including brief provider quitting advice and counselling along with pharmacotherapies approved by the US Food and Drug Administration as appropriate; and (b) health plan or provider payment for the delivery of more specialised or intensive treatments for the smokers who require them.

These recommendations are consistent with the US Agency for Health Care Policy and Research (AHCPR) guideline5 and with recommendations recently set forth by the Center for the Advancement of Health.6

Preliminary interviews with tobacco control advocates in several states in March 1998 indicated that state Medicaid agencies can use their purchasing power, regulatory authority, and convening capacities to encourage healthcare systems to deliver evidence-based nicotine addiction treatment for all smokers. In Oregon, for example, state Medicaid contracts with managed-care plans include participation in selected prevention provisions. Medical directors participating in the Oregon Health Plan, the state’s Medicaid managed-care programme, adopted tobacco cessation as their prevention priority in December 1997 and are now implementing a modified version of the AHCPR guidelines throughout their plans. In Michigan, a recently issued Medicaid policy brief lists nicotine treatment replacement therapies that are covered under Medicaid beginning in 1998. We urge that others explore these programmes as models for their own states.