Trends over time in enrollment in non-group health insurance plans by tobacco use in the United States

Healthcare.gov was created to facilitate the market for non-group insurance in states that did not establish their own marketplaces. In Healthcare.gov, families are asked to report their tobacco use status, and tobacco use surcharges of up to 50% may result. We tabulate enrollment information for 35 states offering insurance plans through Healthcare.gov in both 2014 and 2016. The Centers for Medicare and Medicaid Services provided counts of enrollees indicating tobacco use, by state, year, and risk level. The number of enrollees increased from 5.0 million in 2014 to 9.4 million in 2016. From 2014 to 2016, the number of enrollees rose 39% for tobacco users and 90% for non-tobacco users. Reported non-tobacco user enrollment rose faster than reported tobacco user enrollment in 30 out of 35 states. Reported tobacco users are enrolling in marketplace plans at a lower rate and are more likely to enroll in less generous plans. The decline in smoking as reported when purchasing insurance on Healthcare.gov surpasses declines in smoking observed in other data sources, which suggests that tobacco users may be decreasingly likely to report their tobacco use status accurately to avoid surcharges. Finally, we find no evidence of the surcharges being associated with lower enrollment among self-reported tobacco users, or in rates of smoking.