Travis Douglass

Tobacco use remains the leading preventable cause of death worldwide, claiming millions of lives each year and placing a heavy burden on healthcare systems across the globe. In the United States, Medicaid acts as a critical safety net, offering free or low-cost healthcare coverage to low-income individuals, including seniors, children, and people with disabilities. This federal and state program plays an essential role in improving access to medical care and in reducing health disparities among vulnerable populations. Medicaid coverage includes preventive services, primary and specialty care, and increasingly, behavioral and addiction-related treatments, including those focused on tobacco cessation. For many, Medicaid is not just a benefit—it is a lifeline.  However, recent policy proposals—such as Arkansas’s “Pathway to Prosperity”—raise serious concerns about unintended consequences that could undermine public health efforts, especially those targeting tobacco use.  

The “Pathway to Prosperity” program is a Medicaid reform initiative introduced by Arkansas on January 28, 2025.  It targets individuals between the ages of 19 and 64 who qualify for Medicaid and have incomes up to 138% of the federal poverty level. The program’s goal is to promote economic self-sufficiency by encouraging participants to engage in activities such as employment, education, or community service, and ultimately become less reliant on Medicaid by transitioning to private insurance.  This approach represents a shift away from the traditional model of unconditional access to health coverage. It introduces a performance-based element, where individuals are expected to show personal progress toward economic independence. In theory, this could empower some individuals by linking them to job training or educational resources that improve long-term stability. 

Unlike traditional Medicaid work requirements that demand a specific number of work hours, the “Pathway to Prosperity” program adopts a more flexible approach. Participants are guided to create personal development plans and receive support from success coaches to achieve long-term goals, such as completing education or finding stable employment.  But flexibility alone may not be enough to protect individuals with complex health needs.  While the program is designed with positive intentions, its structure may unintentionally harm people with chronic health conditions—especially those related to tobacco use. 

A major concern is how this program could affect access to essential health services—like smoking cessation support. Smoking remains the leading cause of preventable death in the United States, and for Medicaid recipients, quitting tobacco is often a crucial step toward better health. Currently, Arkansas’s Medicaid program covers a wide range of smoking cessation services, including counseling and prescription medications.  For individuals who smoke, these services can be transformative. Quitlines, nicotine replacement therapies, behavioral counseling, and prescription drugs like bupropion and varenicline have been shown to increase the likelihood of quitting. Access to such treatments can mean the difference between continued nicotine dependence and a meaningful step toward tobacco cessation.  But as the “Pathway to Prosperity” transitions participants from Medicaid to private insurance plans, access to these services may become inconsistent. While the Affordable Care Act (ACA) requires private plans to offer smoking cessation services at no cost, the actual availability and quality of coverage can vary. Some plans may need prior approvals, limit the number of quit attempts, or impose out-of-pocket costs—all of which can create barriers to treatment. 

Such barriers are burdensome for low-income individuals, who may already struggle with housing instability, food insecurity, and limited transportation. Even minor obstacles—like having to navigate a complex insurance approval process—can delay or prevent someone from accessing needed care. 

These inconsistencies can be harmful for individuals who depend on Medicaid to help them quit smoking. Losing reliable access to cessation services could worsen health outcomes and contribute to a rise in tobacco-related diseases such as lung cancer or heart disease. Given the well-documented risks of tobacco use, restricting access to treatment may deepen existing health inequalities among low-income populations. 

For people already living with tobacco-related illnesses like chronic obstructive pulmonary disease (COPD), the demands of the program pose significant challenges. These individuals frequently experience hospitalizations, flare-ups, and serious health complications that make it difficult to engage in employment or community service as required by the program. Many with severe respiratory conditions are physically unable to maintain regular work or volunteer commitments—especially during periods of worsening symptoms.   

Furthermore, imagine facing each day with the weight of cancer’s physical and emotional toll, yearning for respite from the side effects of treatment, yet finding yourself mandated to meet work requirements to sustain your medical benefits. The unpredictable nature of chronic illness makes it difficult to consistently meet program expectations. A person might be well enough to attend a class or job one week but be hospitalized the next.  

Studies show that individuals with chronic illness tend to have lower productivity and higher absenteeism. This reality puts them at risk of being labeled “off track” under program guidelines, which could lead to reduced or suspended Medicaid coverage. This is deeply concerning as people with tobacco related diseases are among those most in need of continuous healthcare.  This raises ethical concerns as well: should access to essential healthcare be contingent on behaviors or achievements that some physically cannot perform? The potential loss of benefits due to non-compliance—however well intentioned the system may be—can lead to devastating consequences for individuals already in fragile health. 

Considering individuals with tobacco related diseases, the “Pathway to Prosperity” program in Arkansas offers valuable lessons for policymakers considering similar reforms. While promoting self-sufficiency is a positive goal, unintended consequences—such as limited access to smoking cessation services and increased health disparities—highlight the importance of policies that support upward mobility without reducing essential healthcare access. 

Health equity must be central to any public health or welfare reform initiative. Policies should recognize and accommodate the real-life challenges faced by individuals.  A one-size-fits-all approach may overlook the diversity of needs and create unnecessary harm.  Policymakers should consider integrating robust safeguards and ensuring that healthcare access remains uninterrupted for those facing medical hardships. Introducing barriers risks pushing people further into the margins, making it more challenging for them to improve their circumstances. By implementing policies that eliminate burdensome benefit requirements, we can create the conditions needed for individuals to focus on their health and achieve lasting upward mobility independently.   

Travis Douglass, MD, FACP 

Assistant Professor of Medicine  

Division of Hospital Medicine  

Emory University Hospital Midtown