The Affordable Care Act contains a number of provisions intended to incent “personal responsibility,” or the notion that health care isn’t just a right — it’s an obligation. None of these measures is more prominent than the law’s individual mandate, designed to ensure that every American obtains health coverage or pays a fine for choosing to go uninsured.
But one provision that’s gotten much less attention — until recently — relates to smoking; specifically, the ACA allows payers to treat tobacco users very differently by opening the door to much higher premiums for this population.
That measure has some health policy analysts cheering, suggesting that higher premiums are necessary to raise revenue for the law and (hopefully) deter smokers’ bad habits. But other observers have warned that the ACA takes a heavy-handed stick to smokers who may be unhappily addicted to tobacco, rather than enticing them with a carrot to quit.
Under proposed rules, HHS would allow insurers to charge a smoker seeking health coverage in the individual market as much as 50% more in premiums than a non-smoker.
That difference in premiums may rapidly add up for smokers, given the expectation that Obamacare’s new medical-loss ratios already will lead to major cost hikes in the individual market. “For many people, in the years after the law, premiums aren’t just going to [go] up a little,” Peter Suderman predicts at Reason. “They’re going to rise a lot.”
Meanwhile, Ann Marie Marciarille, a law professor at the University of Missouri-Kansas City, adds that insurers have “considerable flexibility” in how to set up a potential surcharge for tobacco use. For example, insurers could apply a high surcharge for tobacco use in older smokers — perhaps several hundred dollars per month — further hitting a population that tends to be poorer.
Is this cost-shifting fair? The average American tends to think so.
Nearly 60% of surveyed adults in a 2011 NPR-Thomson Reuters poll thought it was OK to charge smokers more for their health insurance than non-smokers. (That’s nearly twice the number of adults who thought it would be OK to charge the obese more for their health insurance.)
And smoking does lead to health costs that tend to be borne by the broader population. Writing at the Incidental Economist in 2011, Don Taylor noted that “smoking imposes very large social costs” — essentially, about $1.50 per pack — with its increased risk of cancers and other chronic illness. CDC has found that smoking and its effects lead to more than 440,000 premature deaths in the United States per year, with more than $190 billion in annual health costs and productivity loss.
As a result, charging smokers more “makes some actuarial sense,” Marciarille acknowledges. “Tobacco use has a long-term fuse for its most expensive health effects.”
But Louise Norris of Colorado Health Insurance Insider takes issue with the ACA’s treatment of tobacco users.
Noting that smokers represent only about 20% of Americans, Norris argues that “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.”
As a result, she adds, “it seems very logical to say that smokers should have to pay significantly higher premiums for their health insurance,” whereas we’re less inclined to treat the obese differently because so many of us are overweight.
This approach toward tobacco users also raises the risk that low-income smokers will find the cost of coverage too high and end up uninsured, Norris warns. She notes that tax credits for health coverage will be calculated prior to however insurers choose to set their banding rules, “which means that smokers would be responsible for [an] additional premium on their own.”
Alternate Approach: Focus on Cessation
Nearly 70% of smokers want to quit, and about half attempt to kick the habit at least once per year. But more than 90% are unable to stop smoking, partly because of the lack of assistance; fewer than 5% of smokers appear able to quit without support.
That’s why Norris and others say that if federal officials truly want to improve public health, the law should prioritize anti-smoking efforts like counseling and medication for tobacco users. And the ACA does require new health insurance plans to offer smoking cessation products and therapy.
But as Ankita Rao writes at Kaiser Health News, the coverage of those measures thus far is spotty. Some plans leave out nasal sprays and inhalers; others shift costs to smokers, possibly deterring them from seeking treatment.
Some anti-smoking crusaders hope that states will step into the gap and ramp up cessation opportunities, such as by including cessation therapy as an essential health benefit.
“The federal government has missed several opportunities since the enactment of the ACA to grant smokers access to more cessation treatments,” the American Lung Association warned in November. “Now, as states are beginning implementation of state exchanges and Medicaid expansions, state policymakers have the opportunity to stand up for smokers in their states who want to quit.”
Dan Diamond (@ddiamond) is Managing Editor of the Daily Briefing, a CaliforniaHealthline columnist, and a Forbes contributor. This post originally appeared at CaliforniaHealthline.org.
Filed Under: THCB, The Insider's Guide To Health Care
Tagged: Affordable Care Act, Cancer, Dan Diamond, Insurers, Medicaid Expansion, MLR, Obamacare, Premiums, smoking, smoking cessation, tobacco Jan 25, 2013
Smokers absolutely should pay more for health insurance. It’s a disgusting habit and the evidence about its negative effects is overwhelming. Accept the risks, accept the higher premiums.
Smokers damage their health; alcoholics damage their health; people who drink tap water, who drink sodas, who drink fruit juices damage their health. Those who don’t exercise hurt themselves, as do those who eat potato chips and sugar..The list goes on…..Meanwhile, the finger pointing at smokers has no benefit except to those who need to feel superior, often because that’s the one “sin” they don’t have….Fair is fair:if we are to levy financial burdens on those who damage their health, we must include all things that we can agree on which damage health and punish equitably, the self-righteous churchy ones be damned.
Very well said!!! More of the population are obese and that leads to as many, if not more, health problems than smoking. Obesity leads to diabetes, which causes heart, kidney, eye, and nerve problems. Anyone who eats fast food is not eating healthy. As a nurse, I’d rather take care of a smoker who isn’t overweight, than a fat person who can hurt my back when I try to take care of them.
Could you make mention of the SPECIFIC provision the bill that states this? I’d like to see the wording myself. THe problem is, when searching through the text of the ACA for “smoking” the only sections that come up are related to wellness programs, smoking cessation, nothing that says smokers get charged extra. If you could do that for me, I’d appreciate it, since I’m a smoker and so far all I see with these articles is a bunch of smoke, give me substance (specific section in the bill please).
It is not in the law itself but in the reulations promugated by HHS.
I can’t spell. It should be “regulated and promulgated”
Well, you can certainly see why this aspect of the legislation was downplayed during the fight over Obamacare. I get the reasoning, and strongly support the goal, but am a little uncomfortable with the process.
The idea of a democracy is for us to make decisions as a society, with the majority deciding each question before the government. If laws contain laws hidden with laws hidden with laws and questions shielded behind legalistic language, a democracy cannot function.
If we don’t know what we’re voting for, we cannot vote.
The majority hasn’t had a say in anything since obama took over. The majority didn’t want obamacare in the first place. No where does it show that only 10% of smokers get copd or have other problems related to their smoking.
John, if we don’t know what we’re voting for, we cannot vote. That certainly didn’t stop Congress from passing obamacare, did it?
That’s not fair, John. The health law had so many complicated parts and processes, and honest efforts to explain things like wellness counseling were willfully misinterpreted as death panels. What should Congress have done here? Called hearings on every provision of the law?
Yes, yes they should have.
Is there penalty to those on medicare who smoke?
I found this to be a very interesting issue… it certainly goes against the concept of “universal healthcare” as most understand it…
I applied the Law of Unintended Consequences in my own post about the issues you brought up here… http://strangelydiabetic.com/2013/01/25/the-law-of-unintended-consequences/
This interesting comments thread illustrates how incoherent arguments can become.
ACA is as much about insurance as health care. A better name would have been “Health Insurance Regulatory and Reform Act.” In this case it gives permission to (not obligates) insurance companies (NOT government providers — VA, Medicare, Medicaid, Military health services) to financially penalize tobacco users. Even then, there is no obligation for them to do so. Let the free market rejoice.
As usual, risk management (an insurance matter) is being confused with health care (a medical matter). And the issue of costs for both (tax money vs. private money) clouds an already muddy picture.
Two observations. First, I am a total anti-smoker but feel that those who turned 16 before the surgeon general’s warning appeared (not many smokers that age are left in the workforce) should get a free ride on this. Or perhaps for the 5 years or so between when the tobacco companies knew and when the warning appeared, the tobacco companies should pick up the extra premium.
Second, in addition to being multifactorial and sometimes not a choice and much more class-drifven, obesity differs from smoking in not being a 0-1 thing. It is much easier to determine if someone smokes than determine gradations of obesity.
People with IQ’s over 75 have known smoking was not healthy for close to 200 years. I may be a proponent for charging double premiums for willingly ignorant people. It really should hurt more.
Nicotine was first isolated from the tobacco plant in 1828 by physician Wilhelm Heinrich Posselt and chemist Karl Ludwig Reimann of Germany, who considered it a poison.
Historical use of nicotine as an insecticide…
Tobacco was introduced to Europe in 1559, and by the late 17th century, it was used not only for smoking but also as an insecticide.
Interesting. I’m for it. But how would this be monitored? Isn’t it dependent on the smoker disclosing to the insurance provider that they smoke? Couldn’t a person just lie?
Good question. Here’s a cold-blooded answer.
From an actuarial point of view, the calculus by which insurance premiums are based, it’s a moot question. Recent reports are that those who smoke are statistically predictable as a subset (not individuals) to die ten years sooner than those who do not smoke. That means the insurance industry has less to loose when someone lies about whether or not they smoke. The longer they live the more their health care will cost. So dying sooner saves the insurance company in payouts over time.
Will SSI be reducing smoker’s FICA contributions, you know, to be “fair”?
Maybe — in the interest of “fairness” of course — if all his dependents agree not to collect anything upon his death. (FICA is the Social Security portion of payroll taxes, capped so higher-income earners don’t pay as much. This thread is about Medicare, a far smaller portion, but with no cap.)
It would be much better to keep insurance premiums neutral, but to tax the heck out of the substances like nicotine that cause higher health costs.
This is what is done in places like Germany and Japan, which have egalitarian health insurance charges, also have far more smokers than we do, and have better cost control on health care.
A much better alternative, of course, bob. But the US ain’t gonna sit still for any Big Gubmint Healthcare. Free enterprise may have produced the world’s most costly Rube Goldberg health care system on the planet, accessible only by those lucky enough to afford it and covering a footprint in most urban areas as big as an industrial park, but we ain’t gonna let go of that tax-advantaged tit any time soon.
So they are going to extort 60 million smokers because of 440 thousand deaths. To keep us safe, not profit. Right! It’s not about health. It’s about pitting us against one another. Left v right, man v woman, gay v straight, fat v skinny, smokers v non-smoker,etc. As long as we are focused on fighting each other, we won’t stand together against an unconstitutional government passing draconian laws taking away our freedoms. Wake up! Especially you fat people. You are next! If you don’t fight for smokers’ rights now, who will fight for your right to eat what you wish? This is a very slippery slope down to the government controlling all aspects of our private lives. Wake up before it’s too late. Please!
Stephanie, I agree. I’m trying to figure out what I can do about this–little ol’ me, individual. Do you have any ideas?
What do you expect from an administration willing to ignore the will of over 60% of the population and perhaps mortally wound the best health delivery system in the world for over 300 million people to benefit only about 3 million people (those without health insurance, that actually want it and are maybe willing to pay for it (if an insurance company would sell it to them) combined with the administration’s greedy, corrupt, outlaw, cohorts (e.g. Sebelius, Larsen, et al). So, who are the true 1%ers?
At the population level, smokers of a given age cost more to insure in a particular year which should, presumably, be reflected in smokers’ health insurance premiums. For the Medicare eligible population, smokers who choose a Medicare Advantage plan most likely have a higher risk score other things equal which translates to a higher premium payment to the insurer. The fact that smokers die sooner on average and save money for Medicare and Social Security over a lifetime is a different issue. Insurers don’t benefit from that savings though taxpayers do.
At the same time, 40% of the U.S. population smoked in the 1960’s and early 1970’s. Now it’s 20% thanks to much higher taxes, publicity about the harmful effects of smoking and more aggressive cessation efforts. That’s the 2nd lowest percentage in the developed world after Canada.
With respect to obesity, if we could design a tax on unhealthy foods that could be fairly applied and efficiently administered, I would support it. If the cost of products reflect the full social cost of producing them, resources and capital will be allocated more efficiently which will, in turn, make the economy more efficient and competitive. Taxes of this sort, including carbon taxes by the way, will raise money to support government in a way that does much less economic harm than high marginal income tax rates.
I find it hard to believe that lung cancer alone costs insurers enough to justify a 50% increase in premiums. I may be wrong, perhaps someone can let me know.
I suspect that smoking is symptomatic of bad health in many respects — bad diet, stress, and just poverty. You see far more smokers in low wage workplaces than in corporate offices. The problem is not the cigarettes, it is the whole lifestyle.
A 55-year old smoker working for $12 an hour and getting no employer coverage is not buying health insurance today…………..and since the ACA will not subsidize any smoker surcharges, this person will not be getting health insurance in the future. The premium for an older smoker could be $10,000 a year for individual coverage, and the subsidies might defray only about $4,000 of the cost.
This is a ludicrous example of ‘skin in the game.’ The sun will still come up tomorrow if we subsidize older smokers a little more effectively,
I am not a smoker and never have been. But it seems to me that a lot of what is going on with respect to smokers is just “piling on”
The reality is that the LIFETIME medical costs for smokers is LESS than for nonsmokers. (van Baal et al)
http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0050029
It is probable that YEARLY health care costs for smokers are HIGHER, but this effect is overwhelmed by the reduction in costs due to their shorter life span. So if they are to be charged more for health insurance during their working life, shouldn’t they get a rebated on Medicare?
And if we are going to charge more for smokers, shouldn’t we charge more for overweight people, drinkers, motorcycle riders, etc. etc.
Most smokers know that it is a bad habit that will shorten their lives, just as most obese people know that obesity is unhealthy and will shorten their lives. The problem is that stopping smoking or losing weight is not easy and the failure/relapse rate is high.
Rather than trying to punish smokers, I suggest that we just accept them as imperfect people – people who are helping us with Medicare and Social Security by dying early!
No matter how hard we try, we can’t make life completely fair. In Switzerland, for example, everyone over 25 years old, including the elderly, will be charged the same rate for health insurance by a given carrier in a given canton. That’s called pure community rating. However, it means that young healthy people wildly overpay for their insurance relative to their actuarial risk in order to subsidize older and sicker people.
In most suburban communities, at least in the part of the country where I live, roundly two-thirds of (quite high) property taxes pay for K-12 education. If you don’t have children or you don’t have children in school, you pay the same tax on a house of similar value in a given town as a family with several kids in the school system. Indeed, at any given time, only about 30% of households have a child in public school yet we all pay for it through our property taxes. In many of these towns in costs $15-$20K or more to educate each pupil and a lot more than that for special needs children. That’s the way it is and should be, in my opinion.
At the end of the day, I don’t think it’s unreasonable to charge smokers or obese people or people in high risk occupations more for health insurance if the extra premium is an accurate reflection of their actuarial risk. Getting rid of medical underwriting for people with pre-existing conditions or longstanding serious health issues is a major step forward for which healthy people, especially younger people, will pay more than they did before. That’s no small thing in the healthcare and health insurance world. So are subsidies to help lower income people to afford insurance.
I really liked your first two paragraphs, Barry.
As to the third paragraph, covering pre-existing conditions was never a big deal for insurers as long as people maintained group coverage through employers, which is how most people get insurance. The problem was really one of artificial pool definitions in the individual market. The vast majority of young and healthy always subsidized the vast majority of sick people.
The irony here is that by carving out unequal premiums for all sorts of social history risks, and soon probably for genetic and family history risk, insurers are more than making up for inability to charge for medical history risk (pre-existing conditions). It’s a sad joke.
People with wood stoves and old furnaces are charged more for home insurance, it happens every single day, it has happened for 50 years, and no one addresses it in a blog or in Congress.
However — and this is a big however — when it comes to the fire department, people in every American city that has a fire department are charged through taxes, mainly property taxes.
So the person with a new home and a spotless furnace and multiple smoke detectors is charged more in taxes, than the person with an old home and piles of oily rags who burns their garbage.
We make a profound distinction between a public service, which is paid for progressively, versurs private insurance which is paid for actuarially.
(At times the private insurance market does not work, as with floods, and then we have public disaster assistance — though this is messy vis a vis
Katrina and Sandy aftermaths.)
At any rate, in health care we have this ongoing tension between public provision versus private insurance.
The bold solution is of course Medicare for All, but the taxes required are so large that many reformers have backed away from that direction.
Instead we have subsidies of many kinds to “make up” for the unfairness of actuarial private insurance. An economist named Robin Hanson theoriizes that this is because we see health care as a loyalty good, i.e. something we want to give to fellow citizens.
My own prefernce is to expand only Medicare Part A to all citizens, since that focuses on hospital care. I want my neighbor to have hospital care even if he cannot afford it, for the simplle reason that I want to have hospital care when I cannot afford it. (Just like the fire department, eh?)
Bob Hertz, The Health Care Crusade
If and when hospitals transition to ACOs with hospitalists on staff that is a good idea. Unfortunately it’s still hard for anyone to be admitted in many places without a PCP, thanks mainly to a toxic symbiotic relationship between many (most?) hospitals, both for-profit and not-for-profit, and the acres of ancillary services around them. Affordability for health care involves a lot more than hospital care.
I don’t expect to see it in my lifetime, but sooner or later the size of our bloated systems will have to become smaller. That does not mean they will be worse. The result may actually be an improvement as records and consultations become more readily accessible and the savings of travel, time and distance accrue.
Forgive me for repeating what I said elsewhere, but I keep saying it to keep it from eating my insides out. The footprint of most health care systems in America is often as big as an industrial park. There are so many clinics, labs, private practices, specialty centers, agencies, imaging centers, retail outlets selling durable equipment and disposables, pharmacies, the list is endless… And that doesn’t take in to account the ancillary non-medical businesses from window-cleaning, landscaping and waste removal to uniform sales, food service outlets and parking garages. It takes your breath away to think of it. And every dollar supporting this is in one way or another the cost of health care in America. This is madness. Totally crazy. Insanely inefficient.
No matter who pays for it, the system now in place is overpriced beyond measure. As a taxpayer I, for one, don’t really want to keep subsidizing it any more than we as taxpayers are through Medicare. At least Medicaid (like the VA) is allowed to negotiate better drug prices. But until changes are made Medicare continues to be a cash cow of tax money for a bloated, overpriced system.
As for insurance, it seems clear that a public option is a clear alternative, though politically dead, as would be a single-payer option in addition to the private insurance market. Maggie Mahar convinced me that a single-payer system alone really does put too much into the political arena and a competitive private sector alternative serves a real need to keep a lid on costs.
Just my two cents.
I forgot to add one more elephant in the room, long-term care.
Most Americans have no clue that long-term care (where most of them or their family will spend their final months, perhaps years) is not covered by Medicare. At sixty to seventy-five thousand dollars a year that can deplete a lifetime of savings pretty quick. Medicaid is the pitiful safety net for the destitute, but here again is one of the dark secrets of the system we call “health care.”
The protocol for anyone transitioning into long-term care is they must first be an in-patient in a hospital for three days, after which a physician must order them sent to “rehab” typically in a long-term care facility (the new nomenclature for nursing home). For ninety-nine days Medicare picks up the tab, but if by then the “patient” is not “rehabilitated” he or she becomes “custodial.” I hate that word. It sounds like something used in an animal shelter or a Dickensian orphanage.
If the person or family has enough resources the expense will become theirs (though Medicare will continue for medical care alone) but only when they have gone through “spending down” to destitution does Medicaid start picking up room and board.
Next time you hear about states cutting back on Medicaid budgets (or, thanks to the Supreme Court opting out of federal guidelines altogether) make a mental note for the day when you or someone you know tracks into long-term care.
As a non-medical senior care-giver in my post-retirement avocation I see the end of life circumstances up close and personal. It is not a pretty picture, even for those who can afford our services. At least once I saw a man in his eighties still caring for his incontinent spouse who has Alzheimer’s who really needed to be in long-term care. But rather than allowing that to eat up their lifetime of savings he had had her in hospital stays at least three times up to ninety-nine days before bringing her home. I knew the drill. He didn’t have to explain.
I have no idea how widespread this circumstance may be, but it shouldn’t have to occur even once in America. The TV commercials about pushing an old lady off the cliff are not nearly as disagreeable as the reality of what is happening. And the problem is not partisan. It has taken both political parties and decades of political chicanery to arrive at where we are today.
You people are so full of crap. There are many
Other things in society that put all of us at risk
Of something. Now that smokers have to go outside
To smoke it doesn’t affect no smokers health at
All. So stop judging others and trying to strip
Others’ rights. Btw, are you overweight, have
Diabetes that is weight induced, drink alcohol?
When you and your self righteous alliance
Become perfect then you will have the right to
Preach
Health insurers, hospitals and pharmaceutical companies are all raking in record profits. But let’s attack each other and our habits, that will fix things. It’s not like we’re forced to participate in it. Doh!
Stephanie, I hope that was an attempt at irony.
Yes, John. It was.
While we allow the poisoning of our food, air and water, of our bodies, we point our fingers at each other like mad hatters. Historically, finger pointing never ends in a good place.
Ironically, the term mad hatter refers to the fact that historicallly, hat makers (particularly felt hats) were exposed to high levels of mercury (something to do with finger licking) and eventually led to brain damage and dementia, thus mad as a hatter. Funny thing is, insurance carriers understood this fact and would decline to insure these crazy bastards. Good news is under obamacare, we are all treated equally as crazy bastards (except those evil smokers).
John, you are a good and perceptive commentator, thank you.
2 quick comments –
a. last time I was involved with an infirm elderly person, Medicare paid for only 28 days of post-hospital care. If the person did not improve, all payments stopped after 28 or 30 days.
Has that changed?
b. Your comments about the huge footprint of health care in the economy of ciites is interesting in an ironic way.
All of this economic activity is generating salaries for millions of people.
This income stays within America, i.e. hospitals cannot outsource the work of nurses to India, and nurses spend their paychecks in American grocery stores.
Technical economists call this the multiplier. If you pay $1 million in salaries to nurses, it creates $1.5 million or $2 millon or whatever of economic activity overall.
An innocent obsever might ask, why can’t we collect enough taxes from the salaries of health care workers, and from the salaries of the workers who sell them things, to pay for health care?
I am not trained in economics so I would not even venture an answer.
If anyone knows of any writing in this area, please share with me.
bob, it could be that Medicare has shortened the post-hospital room and board expenses to 38 days but I haven’t heard about it. It may also have to do with the specificity of the doctor’s orders. Someone else needs to answer that question.
I have observed a raft of specialty “therapists” plying their respective areas of training with people who clearly had no need of it. For example, a speech therapist spending an hour or two a week with a man who was literally a rocket scientist who was there for an orthopedic condition. Or psycho-therapists and occupational therapists attending elderly residents whose needs may have been clear, but the needs of their peers getting no therapy in the same setting were as bad or worse. I have to believe those hours were carefully documented and billed to some insurance or government source of money.
My experience is informed by having worked in this environment for the last ten years as well as having responsibility for my mother’s care the last five years of her life — two years with us, two more in an assisted care environment and a little over a year in long-term care. We were blessed that she was relatively healthy for someone past ninety (no prescription meds, ambulatory, not incontinent, etc. and a level of dementia that was crippling.) but she had no assets.
As for seeing medical costs as a job source, that strikes me as a false justification for the expense. It’s like saying the same thing about the military-industrial complex. But I don’t want to open another can of worms. I just think we can do much better.
Bob –
We need to be extremely careful in talking about the job creating aspects of healthcare. Suppose, for example, that healthcare costs relentlessly rose to consume 50% of GDP over time and accounted for 50% of the employed workforce. There would be a lot less in the rest of the economy for people to buy and, accordingly, a lower standard of living.
During World War II the economy boomed, we had full employment, but most of the output was going to support the war effort. Consumer goods were tightly rationed. People had plenty of money to buy war bonds but there wasn’t much in the way of consumer goods to be purchased with those paychecks.
We don’t want healthcare costs to crowd out lots of other important and worthwhile priorities from education to infrastructure to housing. If we spent less on healthcare because we found ways to make the system more efficient and cost-effective, implemented sensible tort reform and were able to mitigate the patient culture of unreasonable expectations, we would have more money for other things and jobs would expand to fill those needs and wants.
At the end of the day, it’s not a good idea to spend money wastefully or needlessly even if it creates some jobs in the short term.
Bob, to add to your question, if we add up what we all pay for health care today, including taxes, premiums and employer portion (which we pay for as well), and then divide it progressively amongst all tax payers, why would that amount to unacceptably high taxation?
I vaguely remember having this conversation with Barry a long time ago, and I think he had some explanation. I wouldn’t mind hearing it again…. Barry?
I think way too much speech, occupational and physical therapy provided in a nursing home setting is intended more to drive revenue for the nursing home than to benefit the patient. I suspect that this is especially true if there is a government payer (Medicare / Medicaid) or a private insurance payer (long term care carrier). If the patient doesn’t have an advocate monitoring care, scrutinizing the bills and questioning the people at the facility when necessary, the nursing home will probably get away with it.
In the case of long term care insurers, checks are sent directly to the POA or other authorized representative on behalf of the patient who then, presumably, must pay the nursing home for services rendered in addition to the daily or monthly rate for custodial care.
The bottom line is that when there is government money to be had there will be plenty of people with questionable ethics figuring out ways to rip it off. It’s just another aspect of what I call the fraud culture that permeates too much of the healthcare system in the U.S.
To your point, Barry, here is a link to a comment left at another post “How Doctors Die” just today. The writer, who I think may be a nurse, says in part…
My husband’s condition is irreversible; the only “treatment” is controlling his symptoms to improve his quality of life, but I read Facebook posts about cutting the “waste” in Medicare, knowing they are talking about my husband–his care costs a fortune (I will probably lose my home after he dies). Well-meaning libertarians say it’s up to churches and charities to pay for those who can’t afford care: my entire yearly salary wouldn’t cover my husband’s medical costs. All the while I am told by his doctors that he needs physical therapy, speech therapy, occupational therapy. When I say, “we can’t afford those things,” the answer is “but he needs them.”Do you know how that makes me feel?
http://thehealthcareblog.com/blog/2012/08/06/how-doctors-die/comment-page-2/#comment-323804
That post and comments thread is another place to look to see how our out of control system ratchets up costs during the final days and weeks of life, an easily found and widely accepted statistical reality.
Margalit –
Medicare spending in the U.S. is now north of $550 billion annually of which about 12% is paid for by beneficiary premiums, mostly for Part B coverage including IRMAA surcharges paid by higher income seniors. Federal, state, and sometimes local combined spending for Medicaid is over $400 billion now, I believe. Private insurers pay roundly $800 billion of commercial medical claims including claims paid on behalf of self-funded employers. So, we’re looking at close to $1.8 trillion of payments right there. That excludes another several hundred billion from out-of-pocket costs for long term care, dental and vision care, and normal deductibles and coinsurance payments by individuals and insurance company administrative costs. We also have the VA budget, the NIH budget, the CDC budget and other public health initiatives. You get the picture.
Now go to the CBO website at http://www.cbo.gov and see how much we currently raise from FICA payroll taxes – 12.2% split between the employer and the employee on the first $113,700 of wages and the 2.9% tax on all wages for Medicare Part A which increase to 3.8% this year on income above $250K for couples and also applies to investment income starting this year. Then look and see how much we raise from the current federal income tax which averages between 9.0% and 10.0% of GDP in recent years. Total GDP is $15 trillion or so these days and total healthcare spending is just short of 18% of that number.
Your mention of progressive taxes seems to imply that all we have to do is significantly raise income tax rates on high income people and that will solve the problem. It won’t even come close.
Germany, for example, has a payroll tax of 14.5% nominally split between the employer and the employee but it only applies to the first $65,000 of wages or a bit less at recent exchange rates. The value added tax in Europe averages about 20% and reaches 25% in a couple of the Scandinavian countries. The top income tax rate in many of these countries is not much higher than our new rate of 39.6%. Corporate tax rates in most other countries are actually lower than in the U.S. Only Japan has a higher rate.
The fact is that the European middle class (willingly) pays a far higher total tax burden (income, payroll, value added, property taxes, etc.) than the U.S. middle class pays in combined federal, state and local taxes. The Europeans have long been willing to trade more economic security in the form of a generous social safety net and less income inequality for the likelihood of lower economic growth and less economic opportunity. Even young people coming out of college in much of Europe today are having trouble finding career track jobs with Southern Europe a total disaster in this area.
Americans are simply not willing to pay the tax burden it would take to fund a taxpayer financed healthcare system. The fact that our system costs way more than it should for a whole variety of reasons is a separate issue. For better or worse, it’s the reality we face and most of our politicians, to their credit, know it.
Barry,
By progressive taxation, I did not mean soaking the rich. I just meant fair taxation that will not disproportionately burden the poor. I fully understand that whatever we still refer to as a middle class will have to pay most of it.
Instead of fragmenting the so called risk pools, I just think that it would be more efficient to combine them, since as I said above, one way or another, the middle class is already bearing most of the costs anyway.
As to our legendary land of opportunity, we lost that race as well. Our young people don’t have more opportunity than those in other developed countries, although we still like to think that they do. Inequality may be OK up to a point, but we surpassed that point a long time ago.
Here is a nice article: http://www.newrepublic.com/article/politics/magazine/100516/inequality-mobility-economy-america-recession-divergence#
I’ll post the OECD link separately below
http://www.oecd.org/eco/publicfinanceandfiscalpolicy/chapter%205%20gfg%202010.pdf
You are forgetting many of the “OTHER” taxes and “fees” Americans are charged. The United States is THEE most taxed nation in the world. And, I have in-laws in the UK they DO NOT willingly pay those taxes.
I could list the 100 plus taxes/fees that we in the US pay on a federal, state and local basis. Hell, we have leash laws and they still tax us for having a dog (dog license fee), but not a cat. Also, to hunt and fish (hunting licenses and fishing licenses) and on and on, and on.
Nannnnnnnny State! Lets charge those who embark on personal risk taking adventures like riding a bike in city traffic higher premiums as well. What about those who choose to sail around the world, ride a bike without a helmet. What are the costs to the countless other seemingly stupid behaviors humans engage in? Why not capture them as well?
This does nothing to help smokers stop smoking, it only takes advantage of an addiction. Somehow you anti smoking stiffs feel better about yourselves by punishing smokers under the disguise that you care. Existing smokers are only gonna quit when they decide to…unfortunately for you stiffs, all you can do is state your case for why smoking is bad and hope people choose not to…anything else is unAmerican. These people don’t care that smoking is bad, they just think it’s disgusting therefore their opinion rules over everyone elses. “Smoke and we’ll enforce taxes and penalties, but go ahead and drink until your liver rots out, we enjoy a drink or two ourselves so it’s ok”
This abomination piece of legislation (rhymes with fit) keeps on crapping all over people. Why were smokers picked on rather than alcholics, drug addicts, prostitutes, etc., etc. some of which are much more costly to healthcare costs?
No wonder Nasty Nancy said you have to pass it to see what’s in it, Dirty Harry said we have to call this something else so that 51 passes it rather than 60 which is what it should have been and Obama wanted it set up so all the things that would call the public to “REVOLT” took affect after the 2012 election.
Can’t wait to see what else they’ll try to RAM down our throats.
A product that causes health problems should be taxed when the consumer buys it.
We do tax cigarettes — I am unsure if we tax them highly enough.
Alcohol taxes seem not to have risen for 30 years. Is that a good policy?
Sugary foods are not taxed whatsoever. A gut bomb burger is cheaper than a sprout sandwich.
I would prefer taxing the products, and then charging for health insurance by income.
Actually, sprouts are the number 1 cause of salmonella in this country. But then salmonella does tend to offset some of that obesity, so I guess we at the IPAB will withhold judgment.
I am embarrassed on behalf of these last few comments. This site has its share of divided opinions but rarely do we see this degree of naked ignorance.
America is taxed far less than many other countries as a quick search can verify.
http://en.wikipedia.org/wiki/List_of_countries_by_tax_rates
And if penalties are being forced on anyone it is happening at the hands of the private sector, not the government. In the case of ACA the government is on the side of restricting, not encouraging, how different populations are being penalized.
I think this thread is about finished anyway.
*sigh*
My question is this, if smoking is bad why are cigarettes still sold? It is all a money issue. Why should insurance charge more for smokers when they will not pay for medications that will help smokers quit. Just a fleeting thought….
This will not work. Smokers will chose to not get insurance and pay the penalty tax. then when they get sick will get insurance due to the no pre exisitng condition portion of Obamacare.
This is the same as will happen with the youger generation in their 20s.. Obamacare gives that age group first a 35% then a 45% hike in rates. they will also chose to instead pay the penaly and get insurance when they become sick due to no pre-existing conditions.
The base for funding this whole obamacare is filled with this kind of beyond poor ways they expect to fund it and the whole thing will fall flat on its face.
The penalty tax concept is not all bad.
If 100 people decide not to be insured, and each person pays a penalty tax of $1,000, then the government will collect $100,000.
If 4 persons out of the 100 uninsured get seriously ill, then the government could pay $25,000 each toward their care.
Now the obvious problem in today’s health care environment is that health care providers can charge a lot more than $25,000 for a serious illness.
But that could be thwarted with price controls.
For that matter, the last time I could access the Medicare fee schedule, relatively few procedures cost more than $25,000.
therefore, the penalty tax could work if providers could charge the uninsured no more than the Medicare fee schedule.
Bob Hertz, The Health Care Crusade
The fact is these rules existed already (for the most part). In fact, the statute basically restated the existing regulations with some modifications. The biggest change is the move from 20% to 50% (30% for other health-contingent programs). And plans and insurers still have to offer a reasonable alternative standard if it is unreasonably difficult (or medically inadvisable) for a smoker to quit. Most of those standards oinvolve some kind of cessation program without a requirement that the smoker quit. So the stakes are higher now, but the game is the same.
FROM A NON-SELF DESTRUCTIVE….”NON SMOKER’S POINT OF VIEW”
A SMOKER (DRUG ADDICT) HAS NO-RIGHTS !!
NO ONE HAS THE RIGHT TO AFFECT THE HEALTH AND WELL BEING OF ANYONE ELSE PERIOD.
ESPECIALLY WHEN IT IS THERE OWN SELF-DESTRUCTING BAD HABIT !
ITS LIKE SAYING…..ITS “ALRIGHT TO ABUSE ME WITH YOUR HABIT”.
WE NEED TO SHED THE LIGHT ONTO THE SMOKER (“DRUG ADDICT”) INTO THE PAINFUL REALITY ARISING FROM THEIR HABIT BEING PUSHED ONTO EVERYONE AROUND THEM.
NON-SMOKERS DIE BECAUSE OF THEIR BAD HABIT BEING PUSHED ON THEM !!!
OK, NOW A REALITY CHECK….WHERE ELSE IN OUR SOCIETY DO WE ALLOW A BAD HABIT TO KILL PEOPLE ??
WE NEED TO CHANGE SOCIETY’S CONSCIOUSNESS ON ALLOWING THIS BAD HABIT/ADDICTION/WEAKNESS TO AFFECT THE LIVES OF EVERYBODY AROUND THEM.
WE NEED TO NOT ALLOW THEIR SELFISH, STUPID & STUBBORN ADDICTION/HABIT TO AFFECT OURLIVES.
NOBODY HAS THE RIGHT TO AFFECT THE HEALTH OF SOMEONE ELSE !!
THE SURGEON GENERAL EDWARD C. COOP STATED THAT “A CIGARETTE IS NOTHING MORE THAN A VEHICLE TO INSTALL NICOTINE”, BUT SOCIETY FORGOT ABOUT AFFECTING EVERYONE AROUND THEM….WE NEED TO SHED THE LIGHT…AND SHAME THESE SMOKERS (DRUG ADDICTS) INTO THIS REALITY….AND INSIST ON THEM NOT PUSHING THEIR DRUG/BAD HABIT ONTO ALL OF US.
THEY NEED TO GET THEIR FIX FROM SMOKELESS CIGARETTE’S, PATCHES, ETC….THUS NEVER ALLOWING THEM TO PUSH THEIR BAD HABIT ONTO ALL OF US…
CAN YOU IMAGINE A DAY WHEN YOU WOULD NEVER HAVE TO SMELL THE FOWL SMELL OF CIGARETTE STENCH EVER AGAIN ??
IT IS US, THE MAJORITY OF PEOPLE….(NON-SMOKER’S)…THAT FINALLY DEMAND THAT THIS PUSHING OF THEIR BAD HABIT ONTO US HAS FINALLY NEED TO END!!!!!
A NATIONAL ADD CAMPAIGN TO SHAME SMOKERS INTO KNOWING THIS REALITY/FACT, THAT WHEN THEY SMOKE (WE ALL SMOKE UNWITTINGLY) AND DEMAND AN END….!!
THE ADD CAMPAIGN SHOULD BE BLATANT AND TO THE POINT/TRUTH SHOWING A SCENE COMPARING A HEROINE ADDICT SHOOTING UP WITH THEIR NEEDLE’S AND GETTING THEIR BLOOD ON PEOPLE AROUND THEM, WHICH IS THE SAME AS A SMOKERS SMOKE, BEING PUSHED INTO OUR LUNGS…INHALED THROUGH OUR MOUTH AND NOSE AND CAUSING US TO DIE BECAUSE OF THEIR BAD HABIT..!!
THE TIME IS FINALLY “NOW” TO END….. IT BEING OK TO SMOKE & PUSH YOUR DEADLY HABIT ONTO ALL OF US !!!
Smokers may be “drug addicts” but do you drive a car, put trash out on a curb to be picked up by the trash man, spray chemicals on your lawn to kill bugs or weed, use paper, buy gas from final or any other gas company, or use any product or electric power that pollute the ground,water,or air? Well I’m sure you do. Don’t preach to these people if you do the same thing only in a different way. Its the same thing. Your killing thousand of people a day with your trash,smog,waste water, ect. You can’t preach to the church and be hypocrite.
I smoke for 10+ years, and now a decided to give it up, i found a solution to do it fast http://stop-smoking-with-champix.info/
Well I believe if smokers are going to be made to pay
Higher premiums then so should the obese, who have
Far more health issues than smokers. What about
Alcoholics, they should be included with the
Horrible habit of smoking. It’s easy to pick a group
And ostracize them when you are perfect.
Problem is that none of us are
It should not be fair to raise premiums on smokers due to higher health risk and not raise health premiums on obese. It 60% to 20%. And smokers are only 20%. You can’t criticize the smokers and no one else when it seems like everything you do has a health consequence. It should be equal premiums to allow all aspects people to afford insurance since they seem to think they are not breaking any laws or our rights by making us take insurance. It should be a choice not a law. Same as smoking, just because some people think its disgusting habit doesn’t mean it should turn illegal. Should food turn illegal too since its caused 60% obesity? And to think that congress doesn’t have to abide by the laws. How dare they!!!! What makes them so special and different? And the smoking cessation should be free since the government wants to but a ban on smoking.
Nice site.Here have many suggestion for health tips.It could very benefits not only for doctor but also any companies who are related health.
Attractive aspect to written content. I recently stumbled upon your internet site plus in accession money to claim that I receive in fact adored bill ones web site discussions. In any manner We will be checking in your add to and even I actually good results you have admission to continuously promptly.
Kay, you sound like a ridiculous, whimpering smoker. Sure, all the things you mention DO in fact damage your health to some degree, but not at the level that smoking does. Smoking is absolutely horrible in countless ways for your body. I don’t think it makes anyone self righteous or “churchy” as you put it, for pointing out this fact. I’m all for taxing the hell (that’s what this forced mandate is, a tax) out of anyone with unhealthy/bad habits. The only thing I’m sick from is walking around and looking at a bunch of unhealthy, weak minded, lazy American’s who think they are entitled to everything under the sun without taking any personal responsibility at all for anything they do. Welcome to letting the government take care of you, it’s all down hill from here.