ACA/Smoking

[deleted4401]

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So, I was reading recently that the tobacco companies and the American Cancer Society (as well as other anti-cancer groups) have become strange bedfellows.

Turns out with the ACA, the only factors you are allowed to use to develop premium prices in the insurance exchanges are age, # of people in family, and smoking. If you smoke cigarettes there is an additional fee that is added it on, that is NOT covered by the subsidies for the exchanges

So, for example ... if for a young couple without children that makes $35,000 a year that do not get coverage at work looks for coverage, they may find that the premiums for an average plan are $4000. Their subsidy may be 80%, so they would have to pay $800. However, if one of them smokes, the premiums would go up $2500, so they would have to pay $3300, because that 80% only covers the main part of the premium.

So, basically the tobacco companies are saying this is discrimination and the ACS is saying that the very people that will need insurance down the road are the people that may say, screw it, this is way too much.

At first, I was like of course smokers should pay higher premiums. And so should the obese and heavy drinkers and people with those barbed wire tattooes on their arm. But, then, if we stop doing community rates and start individually assessing everyone, we'll basically price everyone out of insurance except the healthy people, who don't really need health insurance to begin with.

But, mainly I just thought it was hilarious with the head of Altria and the head of ACS joining arms in a cause. I don't really want this to lead to a debate about the ACA.

S

 

[Gfunk6]

That's the beauty of federally run, taxpayer-funded programs. Everyone wants accountability and service but nobody wants to pay for it. Like you said, if smokers don't pay for increased premium, we will all eat the cost at the end of the day from COPD exacerbation and met lung cancer therapy when they come to the ER.

 

[Neuronix]

I've been thinking about this lately...

If smokers die 6-10 years earlier than non-smokers (http://www.nejm.org/doi/full/10.1056/NEJMsa1211128), then smokers would require 6-10 years less of social security, healthcare, and possibly other government benefits for the elderly because they die sooner. Obviously, everyone must die at some point. But, who is to say that dying of non-smoking related illnesses are necessarily cheaper than smoking related illnesses? And if they are, by how much? In other words, if someone dies a protracted death from COPD/smoking, does that cost as much as 10 years of other government benefits until death from something else?

Now from the insurer's standpoint, it makes sense to charge smokers much more. They pay the healthcare and save nothing when the person dies sooner. But for the government, there may be a tradeoff between early smoking related death and the cost of benefits for the elderly.

I wonder if this cost analysis has been done. I'm sure someone has. Hopefully someone can educate me.


(Disclaimer: Please note that I am not advocating for smoking in any way. But I do think all Americans should have affordable or government provided healthcare.)

 

[medgator]

I've been thinking about this lately...

If smokers die 6-10 years earlier than non-smokers (http://www.nejm.org/doi/full/10.1056/NEJMsa1211128), then smokers would require 6-10 years less of social security, healthcare, and possibly other government benefits for the elderly because they die sooner. Obviously, everyone must die at some point. But, who is to say that dying of non-smoking related illnesses are necessarily cheaper than smoking related illnesses? And if they are, by how much? In other words, if someone dies a protracted death from COPD/smoking, does that cost as much as 10 years of other government benefits until death from something else?

Now from the insurer's standpoint, it makes sense to charge smokers much more. They pay the healthcare and save nothing when the person dies sooner. But for the government, there may be a tradeoff between early smoking related death and the cost of benefits for the elderly.

I wonder if this cost analysis has been done. I'm sure someone has. Hopefully someone can educate me.


(Disclaimer: Please note that I am not advocating for smoking in any way. But I do think all Americans should have affordable or government provided healthcare.)

Definitely a controversial area. They may die earlier, but end up racking up more healthcare usage along the way. There are also societal costs with lost productivity etc.

http://bmjopen.bmj.com/content/2/6/e001678.full

Smoking was associated with a moderate decrease in healthcare costs, and a marked decrease in pension costs due to increased mortality. However, when a monetary value for life years lost was taken into account, the beneficial net effect of non-smoking to society was about €70 000 per individual.

http://eurpub.oxfordjournals.org/content/14/1/95.full.pdf

Smoking imposes costs to society even when taking life expectancy into consideration – both in direct and indirect costs

 

[Palex80]

SimulD has a very good point here. If you were to actually "punish" a group of people, because of a habbit, soon you may find out, that noone is going to offer life insurances to sky divers.

I have talked about this issue with colleagues before and we have come up with the following idea:

How about instead of charging smokers with higher insurance fees, you actually impose an extra tax on tobacco directly?

Oneeffect of this could be, that some people may decide to reduce / cut smoking, because it's too expensive.

Now comes the tricky part:
The extra tax should not go into paying for increased treatment costs, since imposing a extra-fee on smoking (either through higher insurance costs or taxes on tobacco) would be a controversial move (just like SimulD said). You should rather use that money coming from the taxes to fund quit-smoking-projects and smoking-related-disease-prevention-projects (for example CT-screening for early lung cancer or hypertension screening, etc...)

In the long term, this may lead to cost reduction in the health system without discriminating smokers.

 

[Ursus Martimus]

Smokers may indeed be less expensive in the end. It is hardly relevant to use a study from England and health care costs to extrapolate to US health care. In England, if you are diabetic and have kidney failure you do not get dialysis you just die of renal failure. This and numerous other examples makes data gleanned from the British system almost irrelevant.

http://www.nejm.org/doi/full/10.1056/NEJM199710093371506#t=articleDiscussion

 

[deleted4401]

It's absolutely relevant. If in the UK, where they spend far less per patient (because of what you have said - no dialysis, no Avastin) and has a population that smokes about as much as ours, and is reflective of our multiculturality, if they show that smokers are a net loss on society, then of course our data will show even more of a loss (since we spend more).

That doesn't make any sense whatsoever to ignore other systems - how do you learn anything? It's not like one country is going to have tons of studies on this topic. Every country that does the study helps us show a trend, especially if you look at direct costs. Indirect costs definitely will vary across countries (places with more social security, higher incomes, etc.) will skew things, but knowing how much comparable nations spend on smokers' health is useful.

Very American to think that other systems are not useful to look at, compare to, learn from and are irrelevant ... That's the sort of thinking that got into this mess. "Best health care in the world ... Let's not change a thing." Now, we're bankrupt and have lousy outcomes.

The fact that we automatically cover dialysis through Medicare is not necessarily a good thing. It's led to widespread fraud and abuse: http://www.cnn.com/2012/11/30/health/medicare-fraud-case. The UK for whatever reasons with their NHS and "NICE" guidelines still have a higher life expectancy than the US, by nearly 2 years, so I don't think due to the NHS/NICE and the lack of coverage for dialysis and other expensive treatments people are dying in the streets. Up to 90-95% of what we do, they do, they just value the very end of life differently and it saves them billions. Not right or wrong, it's just what they've chosen.

No need for overly nationalistic sentiments in medicine ... It's why my favorite Chinese post-mastectomy RT study is always ignored 🙂

S

 

[deleted4401]

Agreed - if you have health care and money, I'm sure the outcomes are equivalent, but at what cost? It doesn't explain why our costs are double most Western countries per capita. One would think by spending that much more per person (insured or not), we'd make up the ground... Different debate for a different thread.

 

[Gfunk6]

To steer this thread back to smoking . . .

Monetarily, it is a lose-lose proposition when you offer smokers health insurance coverage. Either you:

1. Give them the same premiums/deductibles as non-smokers. In this case the cost for the insurance company goes up which, in turn, is passed onto you.

2. Increase their premiums/deductibles for living a high-risk lifestyle. In this case, they may choose to go uncovered and get emergency Medicaid coverage when their habit finally catches up for them and we (taxpayers) are on the hook for the bill.

I think the only solution was alluded to in the NEJM article Ursus posted above. Simply tax the bejeesus out of cigarettes and use that money to further fuel anti-smoking programs. Also, we need to continue to marginalize smokers in society to the point where it becomes intolerable.

 

[medgator]

No need for overly nationalistic sentiments in medicine ... It's why my favorite Chinese post-mastectomy RT study is always ignored 🙂

Don't worry, my favorite chinese elective vs. involved-node lung study gets no love either.

Agreed - if you have health care and money, I'm sure the outcomes are equivalent, but at what cost?

They've actually done some cancer-specific research comparing outcomes between the US and countries in western europe. Our increased spending on cancer care/screening does end up translating into better outcomes.

 

[Neuronix]

I think the only solution was alluded to in the NEJM article Ursus posted above. Simply tax the bejeesus out of cigarettes and use that money to further fuel anti-smoking programs.

I propose an alternate solution: ban cigarettes.

 

[medgator]

I propose an alternate solution: ban cigarettes.

A slippery slope. Is alcohol next?

http://dailyfreepress.com/2013/02/21/alcohol-linked-to-cancer-deaths-study-suggests/
http://www.foxnews.com/health/2013/02/15/many-cancer-deaths-traced-to-alcohol/?test=latestnews

 

[Neuronix]

A slippery slope. Is alcohol next?

There is no beneficial (in my mind "safe") level of consumption of cigarettes. Moderate alcohol consumption has been shown to have significant health benefits (http://www.ncbi.nlm.nih.gov/pubmed/17159008).

 

[deleted4401]

Good luck with that! The tobacco lobby is alive and strong, and politicians will never, ever, ever allow a ban to happen. Even taxing cigarettes heavily (which works) has been left up to the states, and very few do it. I know NYC has exorbitant taxes, but haven't seen data yet about effect on use. But, in the Commonwealth of VA, it's still like $4.50 a pack, and they will fight taxes to the death here, since it's tobacco country.

Has any modern country made it outright illegal?

 

[Gfunk6]

Has any modern country made it outright illegal?

Bhutan banned smoking entirely in 2005. However, it is not well-enforced and (not surprisingly) there is a big black market for cigarettes.

 

[deleted4401]

Only 1% of them smoke. I meant like a modernized country. Sweden did this thing where they basically convinced all the smokers to use snus instead, it's like nicotine candy, don't have to spit. Now, they're all addicted to that stuff and they have the lowest incidence of lung cancer and tobacco-related deaths in Europe.

 

[medgator]

There is no beneficial (in my mind "safe") level of consumption of cigarettes. Moderate alcohol consumption has been shown to have significant health benefits (http://www.ncbi.nlm.nih.gov/pubmed/17159008).

Fair enough. One just has to be careful when trying to legislate behavior.

Only 1% of them smoke. I meant like a modernized country. Sweden did this thing where they basically convinced all the smokers to use snus instead, it's like nicotine candy, don't have to spit. Now, they're all addicted to that stuff and they have the lowest incidence of lung cancer and tobacco-related deaths in Europe.

interesting.

 

[Blammo]

Smokers may indeed be less expensive in the end. It is hardly relevant to use a study from England and health care costs to extrapolate to US health care. In England, if you are diabetic and have kidney failure you do not get dialysis you just die of renal failure. This and numerous other examples makes data gleanned from the British system almost irrelevant.

http://www.nejm.org/doi/full/10.1056/NEJM199710093371506#t=articleDiscussion

Apparently there was a false email rumor going around some time back that the UK NHS does not cover dialysis over the age of 65.

http://www.nhs.uk/conditions/Dialysis/Pages/Introduction.aspx

Here's a story published today in which physicians at an Egnlish hospital got a court order to dialyse a dying patient who had previously refused it.

http://www.telegraph.co.uk/health/h...-failure-patient-forced-to-have-dialysis.html