As a physician I have always been a staunch tobacco opponent just as you'd expect. Opposition to a product, however, should never be equated with opposition to patients, for tobacco use is an addiction, often acquired decades earlier and harder to break than heroin.
There is no doubt that smokers and other tobacco users need to be encouraged and motivated to quit and should not place others in harm's way by exposing them to secondhand smoke. However, the difference between motivation and draconian penalties can be a slippery slope and there is a line, one the Affordable Care Act has crossed.
Among the provisions of the ACA that are now taking effect is one that allows regular users of tobacco to be charged up to 50 percent more of the total premium for their health insurance. Kentucky has set the ceiling on the tobacco surcharge at 40 percent.
On the surface this seems reasonable; the problem is how this penalty is being applied to the working poor and medically indigent. Also, the ACA has no similar penalty for drug or alcohol addiction.
Tobacco use is inversely related to education and income. In Kentucky, 48 percent of adults without a high school diploma smoke. These are the working poor. To help more people obtain health insurance, the ACA will subsidize those whose incomes are between Medicaid eligibility and 400 percent of the poverty level. However, the smoker would have to pay the entire 40 percent penalty without any subsidy.
To make matters worse, the number of individuals caught in this predicament can be expected to increase as employers expand their rolls of temporary and part-time workers to avoid ACA mandates. The Obama administration's decision to postpone the ACA requirement that businesses employing more than 50 people provide their employees with health insurance has placed even full-time workers at risk of losing their health care benefits.
And since there will be no employer penalty in 2014, it is financially beneficial for employers to place full-time employees into state and federal insurance exchanges. This provision will be a financial disaster for many low-income workers who will effectively be excluded from our health care system and may even increase the rolls of the uninsured.
According to estimates by the Kaiser Family Foundation, a 60-year-old non-smoker who earns under $16,000 per year would have to pay $539 in premiums in Kentucky for an individual "Silver Plan" health insurance policy that has a projected average national cost of $8,191.
But if that 60-year-old uses tobacco he would have to pay $3,815 a year. The smoker's premium alone will account for 24 percent to 29 percent of his salary not counting deductibles and co-pays. For a healthy 21-year-old smoker, the same calculation yields a premium of $1,746 in Kentucky.
This is over 10 percent of the young smoker's income and does not include co-pays or deductibles. This policy clearly blocks insurability for the low-income worker.
One might take the callous position of "good for them; they choose to smoke and I do not want to pay for it." However, for most smokers that choice took place in childhood due to deceptive advertising, and once hooked the user is unable to break the addiction. In addition, smokers are more likely to become patients than non-smokers and will end up with advanced disease in the emergency rooms where provision of treatment is mandated.
Thus, we all end up eventually paying even more for their health care due to cost shifting. Wouldn't it be better to provide these individuals access to the health care system where tobacco withdrawal could be encouraged and assisted and preventative care for other ailments can be provided?
The penalty for smoking and tobacco use is often death, but this should not be premature and by the hand of our society. Although personal responsibility needs to be encouraged, changing social behavior by effectively prohibiting access to health care is unacceptable.
We do not have these provisions for individuals who receive Medicaid. Why then are these draconian penalties being applied to the working poor, many of whom are struggling to come off government assistance?