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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 USA, 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 programme 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, behavioural 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.