While the Affordable Care Act ends the era of denying people with pre-existing conditions access to health care, it allows insurance companies to charge tobacco users up to 50% more for their monthly premiums. Tobacco use for this purpose is defined as any self-reported tobacco use four or more times a week within the past six months. There are excellent intentions behind this policy — smoking is the number one preventable cause of death and smokers disproportionately incur health care costs due to the debilitating diseases that result from the habit. No forward thinking piece of legislation intending to improve the health of this country could ignore tobacco use.
However, this smoking surcharge makes the crucial assumption that continuing to smoke is a choice. Charging a higher premium for established smokers will either at best encourage people to stop smoking immediately in order to access health insurance or at worst deter smokers from signing up for health insurance in the first place. Nicotine is one of the most addictive substances known to man and counseling a patient to quit smoking is one of the most impactful services a doctor can provide. Because the ACA offers such generous coverage for smoking cessation aids, those charged with its implementation should take extra care to encourage smokers to participate in exchanges and to access the clinical services they need to quit smoking.
The stubborn presence of tobacco use is frustrating considering the plethora of studies that link it to so many debilitating diseases. Last month, I rotated in the Bronx at a federally qualified health center. There, I saw firsthand the incredibly high rate of smoking in a population that was mostly hidden from me in my everyday life. Though I still occasionally meet someone who smokes, the behavior has mostly retreated from populations of higher socioeconomic status and has burrowed itself and its destruction in low income families. Furthermore, since most people who smoke are of lower income, this results in an additional barrier to coverage when they have to pay an extra premium to receive coverage.
As the fight against tobacco continues to evolve, so should our policy ideas. The tobacco industry needs 5,000 new smokers every day to stay afloat. 88% of smokers began smoking before age 18. Though smoking is often seen as an adult issue, we should continue to support the many excellent anti-smoking campaigns and participate in research that helps us understand how to encourage adolescents that have started smoking to kick some butt.
Carol Duh-Leong is a medical student who blogs at Progress Notes.