About Time? Smokers Face Tough New Rules Under Obamacare

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.

105 replies »

  1. smoking is a choice for everyone who are smokers. but they need to be responsible and consider the people who are nonsmokers. smokers, if you are about to quit but you can’t, read this http://www.suncig.com.au

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  3. Since 04/14 after divulging medical conditions (affected by smoking as there is no safe exposure from secondhand smoke) were brought to the attention of prospective landlords as well as having a child & a cat, they had the wherewithal to advise us it was a dog building due to having a cat but not that they allowed smoking in ALL their buildings because we had medical conditions & a child.

    So after starting to move into this Section 42 Low Income Tax Credit Property, Hinsdale Lake Terrace, were met with severe marijuana odors, reported it to mgmt., which yielded an attitude only to then be bombarded by severe cigarette smoke…requested reasonable accommodation (ie curtailing indoor smoking of ALL types, sealing holes/gaps/etc…to eliminate routes of entry…yet Julie refused to saying they have always been smoking buildings & they were not changing any time soon.

    Their Attorney Todd sent another email 08/04/14, after DuPage Co. Economic Dev was out on 07/30/14 (now an open investigation) stating they would let us out of the lease without penalty & pay moving costs (but we need a security deposit and another willing to reasonably accommodate) so in the interim of this we continued to report to the office the marijuana odors/toxic irritant pollution trespassing our unit as well as the loitering by our door with knocking on wall & loudness late at night, and were advised by their onsite patrol 08/07/14 that their golf carts were taken away by mgmt & responses would take longer only to have this mgmt now give us a 10 day notice to terminate taped to our door 09/04/14, dated 09/02/14, after their online site would not allow us to pay rent like we have done, advising us they are having technical problems with their site.

    The 10 day claimed we were harassing and violating right to quiet enjoyment when all we have done is report to the Office & never confronted any tenant like the one across the hall did to us after she was first given a letter about the loitering but Julie did nothing about that tenant violating our right to quiet enjoyment, harassing us & trespassing our unit.

    The Governor of Illinois has the ability to implement revitalization plan changes for this type of property, it is suppose to be following IRS guidelines appearing to be enforced by IHDA (Ill. Housing Dev. Auth.) whom is suppose to make sure it is safe & habitable (who attempted to put boundaries on the definitions of safe & habitable) appearing to be acting on behalf of IRS & is suppose to follow the Indoor Air Quality Act & ADA (which includes a history of having the conditions not just those receiving disability).

    We continue to have problems with trespass to our unit of the toxic irritant pollutants (cigarette & marijuana…) and this is how we are being done for reasonable accommodation, keeping to ourselves, reporting to the office.

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  6. What I can say is that, smoking is a choice its part of being human and being human requires freedom and that freedom is used but in a different way. It will be good if they would act properly, its not bad to enjoy being free but please take it a consideration to think of others or think of the action before doing so.

  7. These wood-burning stoves are certainly meant to be used outdoors so I can only imagine the air quality in these countries are extremely poor. Improvement in the stove quality will help with the number of cases of lung cancer and other airborne diseases that come from cooking in tight quarters. If there was only more available space outdoors, then this wouldn’t be an issue.

  8. You know what, I’m for an increase in what smokers have to pay. Many smokers try to quit smoking but the motivation to quit was never there. There was never a driving force except loved ones telling you its not good for your health. But now when it hits them where it really hurts (the pocketbook), I bet you’re going to find people really putting a concerted effort into the addiction, whether it’s cold turkey or moving towards the e-cigarettes.

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  11. I didn’t look at it like that… in my opinion it will split 50/50… some people may use it as incentive, others just ignore and be very, very angry that their premiums go up. Only time will tell

  12. i am 100% against smoking and i am also 100% against the higher premiums for smokers through Obamacare. but don’t you all see that Obamacare is setting the higher premiums because he does care? surely its incentive to quit??????????????

  13. yes smokers put their health at risk BUT 50% higher premiums?! Obamacare needs to actually pretend to CARE about smokers and help the 70% who are willing to stop smoking STOP. not just make them pay more money.. at the end of the day paying more money probably wont stop them spending money everyday on packets of cigarettes because it IS and addiction

  14. agree with Isabelle94, and PatriciaBarklay (regardless of the use of the word ‘worser’) however, to be as unbiased as possible, smokers put their health at risk. Fact. but 50% higher premiums for smokers vs. non smokers? Excessive.

  15. being seriously fat is worser than smoking. and ‘NON SMOKERS UNITE’ i would like to know how the drug addicts you describe push the habit on to you?

  16. Smokers should have to pay more for their insurance, BUT so should people who are Obese. American society doesn’t urge people to smoke but it does urge people to eat super-size! What’s all that about? When obese people will probably benefit from the same medical misfortunes as smokers. Smokers are addicts and need the right kind of care to come off of the habit, after all it was society in the 60’s etc that encouraged smoking! It is people who have smoked for years now smoking because it is what their families did when they were younger. Don’t be so quick to condemn and judge.
    In all seriousness, nobody, smoker or non smoker, is going to have a clean bill of health! Inheritance of illness needs to come into account and most importantly so does obesity! Not just smokers should face the hard new regulations under Obamacare, as stated ‘70%’ of smokers want to quit, how about you attack the companies who sell the products to the people who are addicted rather than attack the victims of the addiction? You say they did it to themselves, well so did fat people. And its the fat people that have driven America to become a super-sized nation in need for super-sized clothes and super-sized food and super-sized medical bills…

  17. denied surgery on my neck by Oregon health standerd now have plus will that make any difference

  18. I have been charged for over a year now a (smokers fee )which is actually more than full coverage insurance WTF …so yea the two of them together really takes a huge bite out of my check and i do understand why they think smokers should pay more but come on REALLY …..WE ALL ARE NOT ALL HEALTH FINATICS….so please everybody pointing fingers at smokers….. hello….NO ONE IS PERFECT….honestly it charging me MORE only makes me want to keep smoking because they are trying to FORCE me to quit

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  20. To say that only smokers should pay is just not right there are more people who drink and what.about all of the sexually transmitted diseases and heck and everyone who treats patients woth diseases yhats risky behavior or everyone who works with cancer causing agents thays risky behavior ive knowm ppl who smoked all their lives and never get lung cancer and ppl who say they never smoked and got ling cancer. Also to deny smokers employment is just not right to say u cant have a job cause u smoke but if u drink do risky sexual behaviors which have ppl working with diseases they dont even know they have but can transmit to others. Its not right to pick on one specific population I would call that prejudice. N

  21. Well I will be the first to scream discrimination… Go after the drunks druggies and the obese as well….

  22. What about people who drink, or use recreational drugs, are obese and have type two diabetes, or engage in risky sex? Why just smokers?

  23. Why isn’t smoking considered a pre existing condition? Then when they have subsidized health coverage (or not) they will be afforded programs to help them kick the habit. Why are drug users not charged more? Why aren’t alcoholics charged more as they often times cause accidents and many other variables..

  24. Totally agree with you Stephanie. And I like the ACA. But like they have said before, Medicare & Medicaid had glitches and so will the ACA. We have to be patient.

  25. No, as Medicare is not under the ACA. Medicaid does not have the smoking clause in it.

  26. A smoker in KY will be charged a 40% higher rate than a non smoker. Do a google search for smoking premiums under the ACA. This info is just now coming out and it unfair to single out one particular group/
    Hopefully, this will be repealed after things get off the ground.

  27. Im not wealthy. I work and age 45 to 55. This age group pays the highest health insurance premiums that has tripled in past 2 years while copays and out of pocket cost have increased also. Somebody has to cover the uncovered amounts. Im puzzled over increasing smokers premiums and have not seen, heard or read anything on so called social drinkers or alcohlics paying higher premiums. Look at health related, property damage, increased car insurance, disfigurement and body damage to others, tax increases and so many other problems they cause to not only to themselves but to others. Wow! Major cost in health care and beyond!!! Then, who will pay for the ones who can work and getting free health now? My nickel can’t stretch any further. Look at what is being taken from our seniors health care. Time for the free ride to end. Make them pay for their own gas. I can’t afford them.

  28. D. Walk beat me to it with the caveat about open enrollment. It’s something to think about.

    But you may be independently wealthy with no financial constraints on how much medical care costs. If you feel no civic responsibility to be part of the solution I have no argument to change your mind. I’m sure you are not alone. I see lately an organized Republican campaign urging healthy young people to eschew health insurance entirely, burning symbolic Obamacare cards in protest. That should address the rising cost of health care and make the insurance industry happy at the same time, no?

    In the same way that taxes collected from people without children are used for public education, insurance premiums are collected from healthy people for the benefit of those who need health cafe. But there is little to prevent anyone’s gaming the system.

    I, for one, do not begrudge a singe dollar of health care insurance premium if it means I never use the system enough to “get my money’s worth.” It’s like life insurance. The benefits of “winning” do not outweigh the price of having won.

  29. Be careful about timing your choice not to be insured. There will be “open enrollment periods” and then is when you can apply. If you become ill and it isn’t at the time of an “open enrollment period” you may be in trouble getting care and you won’t be able until the next “open enrollment period”

  30. Well for me as a 52 year old smoker. My ins usage for the last 4 yrs is under 500.00 while my non smoking co worker(s) are each in excess of several thousand dollars year after year. That aside, if you look at just the stats that older smokers have higher health cost, I would like to know for how long? Using those same statistics we are on average going to die 13 years sooner than our non smoking counterparts. What is the cost of paying ss and other age related health costs for an additional 13 years! Also in this figure they lump all health costs regardless of reason together, and call it a “smoking related cost”, things such as arthritis etc.

    In short I have looked at Kaiser’s estimate for my ins premium, it is projected to go from 4212. this year to 11118.00 next year, of which 2180.00 would be subsidized. So before I ever file a claim I will cost the taxpayers 2180 in subsidies and double the amount of my own out of pocket. My solution as I’m sure will be for a lot of folks I will be one of the newly UNINSURED. I will save the premiums I otherwise would of paid and self pay general services. If and when I need more I will then apply for ins(they’ll have to take me) and if I am then that sick I will not be working so would qualify for full subsidy! Hmm problem solved

  31. Smokers are disgusting. We should NOT have to pay for obese, drunks, smokers, or anyone that has taken drugs that has stopped, now having mental problems, or TEENS that does bungee cord jumping, dirt bike riding, some of the stupid things they do to get hurt…I have a family to take care of…as with many other people. As tax payers, we already get screwed by this government to pay for a lot of women on welfare that obviously doesn’t know what causes pregnancies……We lost our jobs last year, I have worked all my life, I asked for food stamps, was told NO, because we made to much last year, again we pay for these BIG grocery stores that pays min. wage, having once again the tax payers paying for their food stamps plus!!!

  32. Geneva, you are clearly working hard and doing a good job keeping your house in order, whether or not you use tobacco. For that you are to be recognized and encouraged.

    But you, like may others, have a seriously misplaced resentment of people receiving public assistance. Phrases like “on drugs and can’t work as they say because the have drug problem.but can get everthing handed to them” reflect not just your impressions but those of manyothers equally misinformed. The fact is that the 1,118,588 adult recipients [of welfare] compose less than four-tenths of one percent of the U.S. population at any given time. The actual number is not only relatively small, but it is a continuously changing group since about half are “cycling” on and off the roles as circumstances change. Here are a couple of links you and others may find informative.



  33. People who pay cash for their insurance should not be charged.People on wefare should be charged.we have to pay fir everyone of these people who are on drugs and can’t work as they say because the have drug problem.but can get everthing handed to them.charge them make them work.and leave the working people aline that is willing to pay for their medical.really no of get paid a whole lot.my insurance cost me half my wages.were is that fair.yes I smoke but 16.00 a week out of my check at 9.00 hour.that adds up to one of bills every month.but I still make it.my bills come to 760.00 a month my insurance is734.00 a month.I have to work 60 hrs a week to to make ends meet.But I’m not on welfareplus raised 3 boys.

  34. This may not make you feel better but it may help explain what’s going on.

    “It’s not just Obamacare: any system that shifts health expenditure from the private sector to the public sector causes transfers like this. If we had no government financing of health care at all, healthy people with high incomes would spend a very small percentage of their income on health care, and the sick poor would spend a large percentage. If we had a fully socialized system where the government paid for everything, rich people would bear most of the cost of providing health care to everyone. And systems that involve a split of public and private expenditure — including Obamacare — have distributional effects somewhere in between.”

    The article is longer than that and does a pretty good job of explaining how expenses are being spread among those who need it.

  35. Good points. You have explained in clear language how the combination of private health care providers (operating at a profit) and private insurance companies (operating at a profit) differs from government provided health care (which is not organized around profitability).

    The high cost of this combination has resulted in millions of people who cannot afford health care at all, which is why ACA was enacted.
    States have different rules, but in most states, uninsured children 18 years old and younger whose family incomes are up to $46,000 per year (for a family of 4) can qualify for either Medicaid or CHIP. America’s so-called “middle class” is rapidly vanishing, being replaced by the working poor. Federal subsidies will soon be forthcoming to assist them buying health insurance through the exchanges.

  36. Well if you are going to charge for supposed bad behavior then do it fairly. Medical costs associated with not wearing seat belts is extream so require the insurance data bank to be notified if you are ticketed. Alcohol same thing, require random testing and if you drink you pay. Then lets get into the people that eat nothing but junk food… terrible habit and associated with heart disease, stroke etc. You could monitor that with debit card purchases. Last but not least all who use illegal drugs or any drug that has a risk of side effects similar to smoking. Since there are 10’s of thousands employed by the tobacco industry in this country so they can just find another job.
    With about 315 million people in the US and 1/5th of them are smokers (abaout 63 million) that currently pay about $1200 per year in taxes on those cigerettes it might be time to realize that will be an additional 75.6 billion in revenue that you will need to make up for. Course the seniors that can no longer afford to pay the premiums and the minimum wage workers I guess are just surplus population so who cares. Having been raised in a household of smokersthat lived into thier mid 80’s, having tried to quit myself just to end up in the hospital on nitro because my body freaked out I guess I have a different view on all this.
    Especially since I have been covered by insurance since birth paid for by my parents and self. What happened to all those premiums? Now in my 50’s you want to penalize me. Well guess that while I paid for all the 20 and 30 year olds that went out and ruined thier livers drinking or using drugs and/or thru fast cars, sports or downright stupidity managed to injusre themselvesI should have been demanding they be penalized. Will start now. That is easy to track….then they can pay for the rest of thier lives. This is opening pandoras box and the results will be nothing like you expect. All for what – insuranc e companies that are a profit source for investors, pay out millions to CEO’s as bonuses every year and provide as little care as possible. My husband just got laid off…..our Cobra is 1367.00 per month if that doubles just how do you think we are supposed to pay for it? Oh thats right working class doesn’t matter either. Since thay only earn about 24000 per year they can just pay it all to insurance and live under a bridge. People you need to get off you high horse and realize that you are just getting played.

  37. 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.

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  39. 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.

  40. 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.

  41. 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

  42. 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











  44. 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.

  45. 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

  46. 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.

  47. 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.

  48. 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).

  49. 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.)

  50. 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?

  51. Will SSI be reducing smoker’s FICA contributions, you know, to be “fair”?

  52. 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.

  53. 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?

  54. 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….

  55. Stephanie, I agree. I’m trying to figure out what I can do about this–little ol’ me, individual. Do you have any ideas?

  56. 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.

    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.

  57. 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.

  58. 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.

  59. 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.

  60. 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”

  61. 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?

  62. 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

  63. 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?


    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.

  64. 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.

  65. 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.

  66. 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.

  67. 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?

  68. 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.

  69. 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.

  70. 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.

  71. 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.

  72. 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!

  73. 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.

  74. 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

  75. 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.

  76. 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.

  77. 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)


    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!

  78. 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,

  79. 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.

  80. 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!

  81. 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.

  82. 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.

  83. 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.

  84. 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?

  85. 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.

  86. 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.

  87. 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?

  88. 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.

  89. 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.

  90. 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).

  91. 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.

  92. 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.