One of the provisions of the ACA is to limit the premium that can be charged for tobacco use in the individual market to no more than 1.5 to 1. So a tobacco user can be charged up to 50% more in premiums than someone who doesn’t use tobacco. That’s still a hefty amount – especially since we’ll likely be seeing considerable rate increases in the individual market next year as policy design – and premiums – will begin to look more like the current small group market, with no medical underwriting.
But back to the tobacco question. I have heard some people complaining that a 50% rate up isn’t high enough, that we should increase the premiums for tobacco users even more. The justification is usually along the lines of pointing out that the tobacco users are making a choice to smoke, and that their choice significantly increases the likelihood that they will experience poor health. One in five American adults are tobacco users… should the burden of paying for their increased healthcare costs rest on them alone, or should it be spread across the other 80% of the population that doesn’t use tobacco?
There are similar debates about whether health insurance premiums should be higher for people who are overweight (they currently are, but won’t be as of 2014). But the debate about weight tends to be more contentious and filled with differing opinions… probably because the majority of the US population is overweight, while the population that smokes is a small minority.
Basically, it’s easy to point fingers and call for increased personal responsibility when we’re singling out another group – one in which we are not included. So for many of the four out of five US adults who are not smokers, it seems very logical to say that smokers should have to pay significantly higher premiums for their health insurance.
When we look a bit more closely at the issue, however, it becomes apparent that a better approach is probably the one taken by the ACA that requires all health insurance plans to cover tobacco cessation programs. Smokers are much more likely to be low-income. And although low-income families will be eligible for significant tax credits when they purchase health insurance via the exchanges, those credits will be applied before any tobacco rate-up. This means that smokers would be responsible for the additional premium on their own (see page 2). This would make them more likely to be unable to afford their premiums and possibly default to going without health insurance and opting to pay the (almost certainly lower) tax penalty instead. More uninsured people – especially those who are more likely to have health issues because of tabacco – is not what we need.
HHS and many state governments have made lowering tobacco use a major priority. Colorado has done an excellent job with improving air quality though public smoking bans (usually widely supported by the general public, most of whom are non-smokers), but we’re sadly lacking when it comes to proving cessation help for those who use tobacco. The majority of smokers (69%) want to quit, but quitting is far from easy. I am among the many non-smokers who are grateful for the improved air quality in public places in Colorado. It’s far more pleasant to be in restaurants and bars now than it was a decade ago, and the impact of second-hand smoke has been greatly reduced. But the population that has the most pressing need for help now is the 16% of Colorado adults who still smoke, and their family members who are exposed to second-hand smoke.
Although higher health insurance premiums do provide a financial deterrent to smoking, the number of smokers who try and fail to quit every year is testament to the powerful nature of nicotine addiction. Providing real support in the form of therapy and/or medication designed to help smokers kick the habit seems like a better solution. Including smoking cessation treatment in the list of preventive services that must be covered by all health insurance plans without cost sharing was a good provision of the ACA. But a study released last fall indicates that implementation of the provision has been inconsistent at best. Hopefully this issue will be fully resolved as new health plans are designed heading into 2014, and tobacco cessation will no longer be a grey area when it comes to health insurance benefits and provider reimbursement.
The best action plan for tobacco is not to punish its users, but to help them kick the habit for good. Rating up their health insurance is a reflection of the additional healthcare costs that they are likely to incur as a result of tobacco use, but providing high-quality cessation programs is more likely to result in the best outcome for everyone: a reduction in the total number of tobacco users.
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