We all know that people who smoke and/or are obese tend to have more medical problems, of greater duration, compared to people with healthier lifestyles. The higher medical costs associated with smoking and obesity translate into higher cost for insurance. As a result, it is no surprise that there is a strong trend among employers to charge more for the insurance premiums of workers who smoke or who are obese.
The Insurance Journal writes that the use of premium penalties is expected to climb in 2012 to almost 40 percent of large and mid-sized companies, up from 19 percent this year and only 8 percent in 2009. An Aon Hewitt survey released in June found that almost half of employers expect by 2016 to have programs that penalize workers “for not achieving specific health outcomes” such as lowering their weight, up from 10 percent in 2011. The premium surcharges usually come hand-in-hand with incentives to quit smoking and lose weight. Unfortunately, the carrot of incentives, by themselves, have not succeeded in lowering health costs. Hence the big stick.
Taxing the Poor?
As is often the case, lower paid workers bear the brunt of the higher costs. Obesity and smoking often – but not always – accompany lower income lifestyles. Low income workers already pay a larger proportion of their income for health insurance; now they will pay more for the consequences of their smoking (a formidably taxed bad habit) and obesity (the result of poor dietary habits). The working poor often live in neighborhoods with limited fresh foods and nothing much in the way of health clubs – which they can’t afford anyway.
There is evidence that the carrot and stick approach actually works. We have written about the Cleveland Clinic, which refuses to hire smokers or obese individuals and which fosters healthy lifestyles among its 40,000 employees. The clinic has seen medical costs grow by only 2 percent this year, far below the national average of 5 to 8 percent.
The Big “But…”
The move to force people into healthy lifestyles does raise a few interesting issues.
1. In cases where obesity or other unhealthy conditions are beyond the control of the individual (genetics, specific diseases, etc.), the higher premiums might be considered discriminatory, although there has been little such litigation to date.
2. Healthy lifestyles (including regular exercise) may well result in higher medical costs for maintaining well-tuned bodies: the ever-growing incidence of knee, hip and shoulder replacements among active people.
2. The goal is to reduce medical expenses, but the leverage exists only with the principal policy holder: there is no way to force other family members to abide by the lifestyle guidelines.
3. The imposition of wellness standards can lead to legitimate privacy issues: for example, holding employees accountable for behavior away from the job (smoking, drinking, eating).
If all goes as planned, medical costs will indeed come down and people will live longer and longer lives. As people with healthy lifestyles live longer, we will have succeeded in transferring costs from private insurers (who cover working people and their families) to social security (which covers retirees). That will require a hike in social security taxes, which the working poor, among others, can ill afford. It seems that every solution carries the seeds of new problems, just as every problem gives rise to new solutions. It is a privilege, of course, just to watch the entire process as it unfolds before us.
Posts Tagged ‘smoking’
Obesity and Smoking: Pay to Play?
Thursday, November 3rd, 2011Annals of Health: Why Smokers Cannot Quit
Monday, September 28th, 2009In all of our discussions about controlling the cost of workers comp, we continually come up against two lifestyle issues that have a direct impact on costs: obesity and smoking. Let’s leave obesity for another day and focus on smoking.
According to a compelling article by Stephen Smith in the Boston Globe, 70 percent of smokers want to stop, but fewer than 10 percent will succeed each year. For non-smokers, this might appear to be a matter of will. But that is both condescending and a gross over-simplification.
Nicotine, the primary addictive agent in tobacco, steals into the brain, setting on fire circuitry that regulates our sense of pleasure [emphasis added]. At the same time, cigarettes acquire a sort of social permanence in smokers’ lives – a way to start the day, to end a meal, to celebrate good times, to muddle through bad times.
Smith uses a rather terrifying analogy to describe how nicotine enters the brain:
Smoking is a uniquely efficient manner of delivering an addictive substance to the brain. “That’s why crack cocaine is so much more addictive than regular cocaine,” said Dr. Nancy Rigotti, chief of Massachusetts General Hospital’s tobacco treatment center. “Cigarettes are kind of like the crack cocaine of nicotine.”
Inhaled nicotine from a cigarette arrives in the brain in 10 seconds. There, it attaches to an especially pivotal region of neurons, those cobweb-like structures that govern our physical and mental actions.
Nicotine, said Dr. Jonathan Winickoff, a tobacco control researcher at Mass. General, “stimulates the same area that get stimulated when you have a wonderful gourmet meal or when you have sexual intercourse. It lights up that part of the brain, which is the rewards center. It drives human behavior. It’s powerful stuff.”
Hmm. Similar to gourmet meals and love making. No wonder people have trouble walking away from the habit, despite the known and often dire consequences of continuing to smoke. It would take powerful medicine indeed to counteract nicotine’s overwhelming appeal.
If there is good news in all of this, it is that a combination of drug therapy and counseling increase the chances of success.
“The data are very clear that you can double your chances if you use a medication if it’s appropriate for you, and you can triple your chances if you use a medication and counseling,” said Thomas Glynn, director of cancer science and trends at the American Cancer Society.
The medicine cabinet now includes seven first-line treatments, anchored by five forms of nicotine replacement. Regardless of the delivery system, the goal is to stave off the withdrawal symptoms and cravings that bedevil so many people who want to quit.
Finally, perseverence is key. You just have to keep at it.
“It takes smokers seven to 11 quit attempts to quit for good,” said Lois Keithly, director of the Massachusetts Tobacco Control Program. “We need to get the message out that if you make a quit attempt and you relapse, you don’t give up.”
Smoking Out Smokers
It will be interesting to see if the nation’s pending experiment with universal health care attempts to tackle the issue of smoking. Will smokers be charged higher premiums? (With a significant portion of smokers qualifying for premium subsidies, such penalties may prove difficult to enforce.) Will the new insurance rules mandate coverage for smoke cessation programs, including the full range of pharmacology options plus counseling? On the one hand, the success rates are low, so smokers are likely to keep smoking; on the other hand, any and all successes project to future cost savings.
Let there be no doubt about how hard it is to give up cigarettes. After all, we have the image of our president: a self-possessed, calm and extremely bright (American born!) man sneaking out of the White House for secretive puffs. Good luck to him and to all smokers who strive valiantly to give up this nasty habit once and for all.
Fire the Smokers! Tax the Fat?
Monday, August 17th, 2009Back in December of 2006 we blogged the story of Scott Rodrigues, a new hire of the Scotts lawn care company, who was fired after failing a drug test. No news here, perhaps, except that the drug in his system, nicotine is perfectly legal. Scott’s is self-insured for health benefits, so they have a vested interest in making sure that employees follow basic wellness practices.
On his way to a pre-placement drug test, Mr. Rodrigues chewed on Nicorette gum. He was trying to kick the habit. Ironically, the Nicorette may have triggered the positive finding for nicotine. Rodrigues was hired provisionally and then abruptly terminated once the test results were released.
Rodrigues brought suit in federal court for violation of privacy and civil rights. Judge George O’Toole has ruled in favor of the company. The judge found no violation of privacy laws, as Rodrigues smoked while walking down the street and in a restaurant parking lot. His supervisor spotted a pack of cigarettes on the dashboard of his truck. Would the judge have ruled for Rodrigues if the employer had peeked through a window to see him smoking at home?
O’Toole also rejected the notion that the firing violated a 1974 federal law that protects employee rights to benefits. O’Toole ruled that Rodrigues was not yet a bona fide employee and was working on the condition that he pass the urinalysis.
Jim King, a spokesman for Scotts, said the smoking ban has never been used to fire an “existing” employee. It is used solely to screen out applicants. Since the ban went into effect in 2005, the percentage of smokers among the company’s 7,000 employees has fallen to 7 percent from 28 percent.
[The Insider notes in passing that even as a “provisional” employee, Rodrigues was covered by workers comp from the moment he began working – indeed, while he was on his way to the drug testing lab.]
Whether employees can smoke or not depends upon the state they work in. A few states (e.g., Kentucky, Louisiana) explicitly protect smoker rights. Other states do not. It’s interesting that Rodrigues pursued his case in federal court, probably because Massachusetts laws offered no protection to smokers.
Is Obesity Next?
We all know that smoking increases the risk of illness and the cost of medical coverage. The same goes for obesity. So the next front in the battle to control the business side of medical costs may well be the bathroom scale. The New York Times magazine profiles the Cleveland Clinic, which has been upheld as a model for medical cost control. Two years ago, they stopped hiring smokers. Delos M. Cosgrove, the heart surgeon who is the clinic’s chief executive, would like to expand the hiring ban to include applicants who are obese.
“Why is it unfair? Has anyone ever shown the law of conservation of matter doesn’t apply?” Cosgrove states that people’s weight is a reflection of how much they eat and how active they are. The country has grown fat because it’s consuming more calories and burning fewer. Our national weight problem brings huge costs, both medical and economic. Yet our anti-obesity efforts have none of the urgency of our antismoking efforts. “We should declare obesity a disease and say we’re going to help you get over it.”
Should the Cleveland Clinic – or any other employer- decline to hire obese people, it will be interesting to track the results. Where obesity can be traced back to genetic or chemical issues – where it qualifies as a disability under the Americans with Disabilities Act- employers would be guilty of discrimination. If no such causes can be specified, employers may be on solid ground. (The unaddressed issue in these hiring practices, of course, is the loss of a vast pool of talented and often essential workers.)
A recent article in Health Affairs estimated the annual cost of obesity to be $147 billion and growing. That translates into $1,250 per household, mostly in taxes and insurance premiums.
The Fat Tax
Cosgrove is interested in an idea that some economists favor: charging higher health-insurance premiums to anyone with a certain body-mass index. Call it the Fat Tax. Another alternative might be taxing the calorie-rich foods that lead to obesity: just imagine paying a little surcharge for your large order of fries, your jumbo soda and your two-for-one pizza. That would be interesting, indeed! Just as smokers pay a tax-driven premium for their cigarettes, eaters would be taxed for their food addictions.
This is simply not going to happen. To be sure, fundamental wellness is the cornerstone of any plan to contain health care costs. But when the public good collides with the rights of freedom and privacy, individual rights will win out. Policy wonks may not like it, but citizens can eat whatever they damn well please. Lighting up after that supersized meal? Well, that’s one area where the public good pretty much trumps the private right.