Sunday, October 23, 2011

Should Wal-Mart Make Smokers Pay More for Health Insurance?

A recent article about changes Wal-Mart is making in its health insurance program reports that smokers will be required to pay an extra $10 to $90 each pay period — $260 to $2,340 a year.

Is that fair?

Greg Rossiter, speaking for Wal-Mart, defends the policy on the basis of cost - “Tobacco users generally consume about 25 percent more health care services than nontobacco users.” But patients with cancer also "consume" more health care services. I doubt that Wal-Mart intends to raise their premiums.

Wal-Mart doesn't justify the tobacco penalty by cost alone, but rather by cost combined with the conviction that smoking represents a choice.

Smoking is obviously harmful, and smoking cessation will be good for the individuals who stop, the cost of the corporate health program, and the impact of secondary smoke on others. But Wal-Mart's program is wrong.

Nicotine is addictive. Addictions don't stop on a dime. Here's what I would have recommended to Wal-Mart:
  1. "If you haven't done it already, involve a council of "associates" (the Wal-Mart term for employees) in developing the policy re smoking."

  2. "Give associates advance notice of the financial penalties - no less than a year, perhaps two."

  3. "Offer strong support for smoking cessation."

  4. "Make sure the financial penalties aren't 'too large.' The aim of the penalty should be to focus attention on tobacco use and send an educational message, not to cover the incremental cost of health care. $2,390 is way too much for anyone but a senior executive."
A country with a tax-supported health system that covered all citizens would locate incentives where they belong - at the point of purchase, not as part of the health insurance premium. Tobacco, beverages with high sugar content, and other products that harm individual health, public health, and add to the deficit, would be taxed at a high enough level to create a disincentive and to account for the costs the products create for the public.

I'm entitled to smoke if I wish, but I'm not entitled to make you pay for the future costs my smoking entails.

Given our reliance on employer-based health insurance for 60% of the population, it's ideal for employers to take a public health orientation towards employees. I think Wal-Mart is right to take on smoking as a public health issue for its employees, but clinical and ethical considerations require it to modify the way it's approaching the issue.

The Good Samaritan didn't ask the wounded traveller if he'd brought on his condition by faulty choices!


Anonymous said...

My employer also does this, but rather than "charging" smokers extra, it is framed as a reward for those that don't smoke or quit within a certain period before the change in premium. To further offset the penalty, there is a positive rewards program. Associates can self-report healthy behaviors (exercise, good nutrition--even flossing teeth regularly) on a weekly basis on the plan's member Web site. Those achieving a certain number of points per quarter receive a cash reward. This is large enough to offset the smoker's extra contribution. So if you're one of those that hasn't successfully quit, you can make it up in other ways. It also focuses attention on the positive things you can do to improve your health.

I do have a concern that certain behaviors are singled out. Who makes those choices? I worry about a group of associates doing it. I recently saw a focus group discussion where associates were very negative toward diabetics, assuming that this disease is the result of lifestyle choices, which of course is only partially true! If we slide down this slippery slope, we might next target certain cancers (e.g., lung) as being lifestyle consequences, which is not universally true either. Some lung cancer victims never smoked, while others with a 75+ pack-year history never get cancer.

This is not to say we shouldn't go down this road, but I challenge corporate bioethicists to set very careful boundaries to prevent unfair discrimination.

Jim Sabin said...

Dear Anonymous -

Thank you for your VERY thoughtful and informative comments.

I'm impressed with the way your employer handles the area of health engagement:

(1) Giving a "reward" for not smoking rather than a "penalty" for smoking is good behavioral economics. Our jail population demonstrates that penalties don't cure addictions. Positive incentives work better.
(2) The weekly self-reports of health promoting behaviors makes good intuitive sense. 12 step programs make excellent use of the same mechanism (strengthened, of course, by group participation).
(3) Providing a mechanism whereby folks who haven't succeeded in tobacco cessation offset the financial loss that comes from smoking makes good clinical sense. Smoking isn't the only health-relevant thing we do. If a smoker exercises, eats well, and loses weight, those would be positive steps.

You're quite right to be concerned about the potential for stigma and discrimination. The focus group you describe demonstrates that risk and the importance of public education.

Re your suggestion that ethicists provide a framework for constructive, fair, and non-discriminatory health programs, the next meeting of the health plan ethics committee that I chair will discuss that very topic. I'll probably write more in the blog after that meeting. I may quote from your comment in the material I prepare for the group!

Again, thank you!