The Affordable Care Act and the Smokers’ Penalty

Under the ACA smokers  buying insurance in the Exchanges will have to pay a 50% “Premium Surcharge.” For a 55-year-old smoker, the penalty could reach nearly $4,250 a year. Does this mean that Americans who smoke won’t be able to afford coverage?

No. In the end, most smokers should be able to get health insurance without paying a stiff penalty.

For one, it’s up to individual states as to whether they want to let insurers charge smokers more. By early April of 2013, Rhode Island, Vermont, Massachusetts and D.C. had voted to eliminate smoking premiums in their health care exchanges:  The American Cancer Society, which is opposed to the surcharge, is working to persuade other states to ban it. (The ACS explains: “We’re anti-smoking, not anti-smoker.”)

I agree with the ACS that the penalty is counter-productive.  If it makes insurance unaffordable for some smokers, this means that they won’t have access to smoking cessation programs, nicotine patches and other drugs that could help them quit.  Keep in mind that most smokers want to quit, and these programs have proved extremely successful.

The good news is that many Americans who are addicted to nicotine will be eligible for Medicaid. In the U.S. 39 percent of adult smokers live below the poverty level. . Many more live below 133 percent of the poverty level. As states expand Medicaid, they, too, will become eligible for the program. Since Medicaid charges no premiums, they will not pay a premium surcharge.

Meanwhile, new research by the George Washington University School of Public Health and Health Services indicates that including comprehensive tobacco cessation benefits in Medicaid insurance coverage can result in substantial savings for Medicaid. The study found that every dollar spent on tobacco cessation program costs resulted in an average program savings of $3.12, which represents a $2.12 return on investment. 

Under the Affordable Care Act all state Medicaid programs are required to cover tobacco cessation medications, beginning in 2014.

Finally smokers who receive health benefits from their employer are likely to find that they don’t have to pay the premium if they join a smoking cessation program.

23 thoughts on “The Affordable Care Act and the Smokers’ Penalty

  1. A punitive attitude to any health issue is inane – and this is especially true when it comes to addictions. The only approach with any credibility is rehabilitation and perhaps rewarding rehab. However if we are going to penalise people for their lifestyle choices – at least as far as health insurance is concerned, then I propose a star rating system where the higher your star rating, the more you pay.

    Smoker: 3*
    Alcoholic: 3*
    Heroin addict: 5*
    Meth addict: 5*
    Obese person: 5*
    Motorbike rider: 4* (3* discount for carrying organ donor card)
    Sky Diver: 1* (they seldom need medical help)
    Non-exerciser: 4*
    Lawyer: 1*

    • Brian–
      “Inane” is the right word for such penalties.
      I particularly liked the discount for motor bike riders who carry an organ donor card.
      I hestiate to ask how lawyers made the list . . .

  2. I think I follow the sky driver rating, but why the low star lawyer rating?? Curious minds wish to know. Otherwise, good post!

  3. Ng-\
    Yes, the sky diver rating makes sense, but I too am curious about the lawyers.

    • As the Western World become more authoritarian and imposes endless regulations and new laws on us, lawyers are more powerful than ever before. Doctors fear lawyers more than anyone else so they need to be given preferential treatment and we should never charge them more than 20% of their average rate. Last night at the annual dinner of the Jewish Medical Association of the UK, the Israeli ambassador, Daniel Taub made this joke about lawyers:
      A man noticed a gravedigger digging a particular deep grave in a cemetery (‘graveyard’ in American). He asked the differ why he was doing this. The digger said he needed to dig a 50 feet down because the man being buried had been a lawyer. ‘But why does he have to be buried 50 feet down?’ asked the puzzled man. Replied the grave digger: ‘Because deep down, even lawyers are good people’

      • Brian–


        I should add that we shouldn’t blame lawyers for govt regulation.

        They dont’ make the laws, they just enforce them. And in many area, we actually need more regulation . . .

        • ‘ They don’t make the laws’
          In the immortal words of your great countryman, John McEnroe: ‘You cannot be serious!’ If what you say is true then I really misunderstand politics in the USA. It seems that my understanding that becoming a congressman or a senator was a LEGAL SPECIALITY on your side of the Atlantic (and increasingly so on ours with war hero Tony Blair leading the pack) What % of your politicians (aka as ‘lawmakers’) are lawyers? Okay this is what I found out on Google.

          Out of a total of 435 U.S. Representatives and 100 Senators (535 total in Congress), lawyers comprise the biggest voting block of one type, making up 43% of Congress. Sixty percent of the U.S. Senate is lawyers.
          Enough said’ Your president is a lawyer like many of his predecessors. I do understand that Obamacare does nothing to reduce the inane cost of tort to everyone (except lawyers) of course is utterly unrelated to the fact that lawyers are running America because it’s not the SAME LAWYERS who are referred to in your post. Nevertheless I maintain that lawyers do make the laws in America and the laws they make are generally good for all lawyers.
          This is not to say that ALL lawyers are corrupt crooks. America has produces some truly NOBLE LAWYERS, the most recent example I can think of is Clarence Darrow. and that was not so long ago.

          • Brian–

            You are right– a large percentage of our politiicans are lawyers. But they are not practicing lawyers. Many have never practiced–or only briefly. In the U.S. law school is a route to politics.
            It’s not clear that the lawyers in Congress identify with lawyers–as a group– so much as they identify with business and wealth.
            To be elected they depend on contributions from corporations and wealthy Americans. This is particiuarly true of REpublicans and Conservatives. (As you know, corporations and very wealthy individuals are less likely to contribute to Democrats Too many Democrats favor safety net programs, more equal distribution of wealth, higher taxes for the wealthy, and government regulation.
            On the question of torts and tort reform, both corporations and wealthy sharehoders object to all types of consumer suits- not just for malpractice but defective products because these suits can have a devastating effect on profits. Coroporations and wealthy sharholders would like to get rid of the plaintiffs’ bar altogether.
            Democrats, by contrast, tend to represent consumers and defend their right to be compensated when they have been hurt by
            Increasingly, Democrats will be relying on African Americans, Hispanics, women, Asians and new immigrants to vote the into office.Last year, for the first time ever, the vote turnout among African Americans was greater than the turn-out among
            non-Hispanic whites. See this Bloomberg article:

  4. I can’t keep in mind that most smokers want to quit, because smokers who want to quit do so. Other smokers claim to want to quit, and even submit to programs or magic pills to prove their non-desire. The smokers penalty is ridiculous, but is part of the socially accepted intolerance and hatred toward smokers.

    • Myra–

      I agree that socially accepted intolerance and hatred toward smokers is horrible.

      On the question of how easy or hard it is for smokers to quit,I have to say that I’m old enough to remember when there
      were no nicotine patches or good drugs that helped. Most people I knew tried very, very hard to quit–and failed. Sometime they quit for a while-then went back to smoking. Some succeeded only after 3 or 4 attempts to kick the habit. And these were not poor people who had little reason to value their lives.

      The research shows that it has become much more likely that smokers will succeed in quitting now that we have nictone patches, other drugs and the excellent help that smoking cessation programs now provide.

  5. Maggie,
    I don’t buy your two party system there and I don’t buy ours here. Your democrats can best be described as the ‘good cop’ in the good cop/bad cop scenario that happens in the USA. This is not to say that the content-free campaigning ‘full of sound and fury and signifying nothing’ is not without amusement value as your professional politicians battle it out giving the sheeple the IMPRESSION that they have some say in the way they are ripped off. “Everybody knows. The rich get rich the poor get poor. That’s how it goes. Everybody knows.” (Leonard Cohen) Take your pick sheeple. Who do you want to be ripped off by? The liars or the crooks?
    And getting back to smoking. It’s possible that smokers actually save money for countries who have welfare. They tend to die young. Oh how you miss Hunter S. Thompson, George Carling and of course Lenny Bruce.

    • Brian–
      “The rich get rich and poor get poor. That’s how it goes. Everybody knows.”

      Clever lyric, but not true.

      During the 1960s, our war on poverty worked. The number of Americans living below the poverty line fell sharply.
      In general, during the 50s and 60s, the gaps between the rich, the middle class and the working class were much
      narrower than they are today. (Here, I’m talking about the white population. Minorities were much poorer than everyone else.)

      Beginning in the 1980s,we lost interest in both the poor and the working class. The gaps widened.

      In the U.S., a higher percentage of our children are living in poverty than in any other nation in the world.

      But we do have some politicians who care: Jay Rockefeller, Elizabeth Warren, Corey Booker (African-American mayor of Newark who is heading for the Senate), Hillary Clinton (who may well be our next president) Obama (He’s hardly LBJ,
      but he did refer to “poverty” four times in his state of the union address, and called for univeresal pre-school and raising the minimum wage)Senators Tom Harkin and George Miller (who would raise the miniumum wage from $7.25 to $10.10) . ..

      I could go on. And in the years ahead, it looks as if more women and minorities will be heading to Congress.

  6. I personally don’t have any haterd or intolerance to smokers. whatever lifestyle and habits people want to have is their own choice, but with that choice comes a personal responsibilty, not a social responsibility, so if a smoker is more likely to have health problems, then they should have to pay for that, not the everybody else.

    • Gabe–

      The problem is that nicotine is addictive–very addictive. Once hooked, it’s v. hard to kick the habit–especially if you
      are poor and depressed. This is why the majority of adult smokers in the U.S. are poor. Many suffer from mental health problems such
      as chronic depression, schizophrenia, paranoia, etc. (Healthier wealthier Americans have more reason to want to take care of themselves.)

      Nicotine patches and new medications have made it significantly easier to quit. But poor people can’t afford them.
      The ACA does offer free counseling and medication for smokers. This should really help. But if the penalties for somking make the premiums too expensive for them to afford, they won’t be insured, and won’t get that help.

  7. Pingback: The American Spectator : Latest Obamacare Foul-Up Favors Smokers

  8. After reading this, I have to say I agree with the ACS explanation of being “anti-smoking, not anti-smoker.” I’d put myself in that category because if we alienate the smokers from affordable coverage, then we’re just reinforcing the same problem Obamacare is trying to solve in the first place. Lets keep our nation healthy in the first place so we don’t have to pay the higher price and repercussions down the road.

  9. A tax deduction worth $20,000 for families and $7,500
    for individuals to allow them to buy health insurance in any state.
    The new law allowed children to be covered under parents’ health
    plans until children became 26. As time closes in on the Accountable
    Care Organization model of healthcare under Medicare, physicians across the US are busy realigning their practice models and alliances in congruence with the mandate of Section 3022 of the Patient Protection and Affordable Care Act (ACA).

  10. After 47 years of smoking combustible cigarettes and nine cold turkey and nicotine gum attempts to quit I found the electronic cigarette. There is more to cigarette smoking than the nicotine. I congratulate people who have succeded in quiting ALL nicotine. At this point I am not one of them. The ACA considers NRT a tobacco product although I have failed to find any evidence that nicotine replacement products cause cancer, COPD or heart disease. The e-cigarette (they should change the name) is controversial and must be tested for safety but it has been a life saver for me. I have not smoked a combustible cigarette for over 6 months…my tenth attempt! This device satifies the cravings of not just nicotine but the entire smoking experience. See Dr.Michael SiegelI Utube video on this subject. I will still get penalized on my health insurance because I am a “tobacco user”. A tobacco user is anyone who uses any type of NRT for greater than 6 months. I don’t know how long I will use this but I have already cut down on my nicotine strength to 1/3 of where I began and use 0 mgs some days. This has been more effective than gum and drugs.
    The FDA is is saying NRT can be used safely for longer term use but as usual their report has been delayed.
    Did anyone read about tthat hospital that refuses employment for anyone with a BMI of 35 and above? True…google it!
    The government is not just coming after smokers they are coming after the obese, diabetics, weekend drug and alcohol users, and yes skydivers.
    Anyone that sugggests that because nicotine is a stimulant (as caffeine is) and that it is somehow equivalent to a combustible cigarette or that everyone will be off NRT after 6 months is smoking something funny.
    I am proud that after 10 attempts I quit smoking. But to the ACA I am not an ex-smoker I am now labeled a nicotine addict. Damned if you do and damned if you don’t. I really want a combustible cigarette…why not? THAT my friends will be the attitude of every 10 year NRT gum chewer, e-cig user that will be forced to quit their enjoyable innocent stimulant because it’s not good enough just to quit the combustibles. They want more and nore and more…….

    • Pam–
      The Affordable Care Act does not penalize people who are obese because we know there is no medical cure for obesity.
      Numerous studies show that even if a patient exercises and diets faithfully, under a doctor’s supervision, 98% of patients regain the weight. This is very sad and there is little we can do except — radical surgery (which leaves some people extremely depressed and bedridden) and, most importantly working to avoid obesity among children.

      For obese adults the best treatment is cardiovascular exercise. Even if they don’t lose weight, they will be much healthier and less susceptible to heart disease and other diseases.

      By contrast, we do have good cures for smokers. Not “nicotine gum” but nicotine patches and other new drugs that are extremely effective. Under the ACA smoking cessation programs are considered “preventive care” and so they are free.

      There is really no reason not to enter a program.

      You are right that addiction to smoking is about more than the nicotine. When I was young I was a heavy smoker. When quitting I learned that there are many things you can do– for instance when writing, talking on the phone, or reading (times that I always enjoyed smoking) I learned to sip iced tea or club soda. After a while, constantly raising my hand to my mouth felt almost like smoking.

      Finally, as you say, e-cigarettes are controversial, and I think, with good reason.

  11. I could kick myself. I re-upped for the ACA this year, with no changes to my lifestyle or income. I was never informed of the smoker ‘glitch’ by anyone at HHS, ACA when I called to ask and bitch about my premium going from $15.88 a month to the 2015 premium of same policy/company of $316.00. I appealed my application with ACA/HHS and, to date, no one has simply explained that the programmers were unable to get the smoker penalty in the system last year. Having been a surgeon’s assistant prior to my retirement, I object to this penalty for all of the obvious reasons regarding the smoker being picked out as the only pre-existing money maker for those states that like the ‘get rich’ scheme it easily brings them. I am a healthy, extremely infrequent utilizer of my health insurance other than for health maintenance and a very tardy seeker of healthcare when I do get a cold or have a pain. People I meet are absolutely shocked to find that I am a smoker. That is because I have no physical ailments or physical appearance of being one. My arteries are in better shape than most non smokers, my lungs work very well and I can work circles around any 30 year old. I am 63 years old and my only human ailment is that of chronic depression which I have fought my entire lifetime only to surrender to it and take a pill every single day to keep the “Black Dog” at bay. I am grateful for it because sitting for hours staring at the rug pattern on my floor is no way to live. Depression is ugly and prevents me from ‘being me’. It is as real as chronic bowel disease that forces one to wear a diaper. The fact is, mental illness patients are avid smokers whether they want to be or not. The reasoning cannot be explained by professionals in the mental health field but they accept it as a ‘part’ of these patients in their care and feeding. I smoke about 10 cigarettes a day and I cannot explain why I am unable to stop smoking (though I have tried repeatedly…). I have never been uninsured in my LIFETIME until the recession and loss of my job at the ripe old age of 60. I apply for work EVERY single day, without result. My state is Virginia. Virginia is the epitome of wanting annihilation of the poor and mentally ill. The only reason this state legislature has turned out a 2015 budget with expanded mental health money in it is because our very fine state Senator Creigh Deeds’ son, went berserk and tried to kill his father and then himself on their farm in recent years. That poor man was unable to find a bed for his mentally ill son when he urgently reached out for help prior to the son’s breakdown. Our state refuses the Medicaid option. The only reason I opted to retire at 62 was because my SS widow’s benefit (my only form of income after job loss…) was not enough to allow me to apply for ACA. My SS income increase just a few hundred dollars and that was my pass to be insured again. While I continue to be hired for a job, my income remains at $1,076.00 a MONTH. I take ONE pill a day so that I am able to take a job and be ‘normal’. Without health insurance, I developed a gastric ulcer from worry and now have been given a daily pill that costs over $400.00 a month without insurance help. As I explained to ACA and HHS, I signed up for insurance again this year (without knowledge of the smoking penalty) but cannot pay for it. Hence, I am once again without health insurance and will be obligated to pay a penalty for having not agreed to the $316.00 a month that Anthem can legally charge. Having had a medical/surgical background, I am so angry about this I could spit. A better and more fair assessment of a penalty being imposed would be for each applicant to simply send in their most recent full scale laboratory blood draw report that includes all organs of the body that would indicate their utilization habits and cost of care for ALL ‘choice’ ailments. Let’s face it, I love sugar, too. We have states that are about to put the lid on that money maker from the pancreas. Get ready folks…it will cost you a lot more to pay for my medical care when I am forced to use the ER for a runny nose or worse – as was the habit of the uninsured for eons! Now hear this: 30% of those formerly uninsured habitual smokers with mental illness or in poverty will be back on the ‘dole’ real fast. I have joined those I used to despise as being free loaders. So be it.

    • Jane–

      I think the smoker’s penalty is too stiff– mainly because the vast majority of smokers are poor.

      These days, very few college-educated Americans smoke.

      I can’t explain why cigarettes have not harmed your health.

      This is extremely unusual–and I have to wonder if it is true. You may not have diagnosed, but down the road, it’s possible that you will develop heart disease, or one of the other diseases that affect smokers.(I sincerely hope I’m wrong.)

      Going back to your complaint: the smoker’s penalty was designed to give smoker’s an incentive to quit. We know that they can quit–nicotine patches, counseling and other medication work. We don’t really know how to help people suffering from many other addictions–including alcohol.
      Even when they receive good professional help, alcoholics often go back to drinking.

      But we can help smokers–thus, the penalty if they keep on smoking.

      The penalty also helps pay for the extra healthcare that smokers usually (eventually) need.

      If in fact, you are that rare person who is not hurt by smoking, then you won’t need extra healthcare.

      But if so, you are a very care case. You cannot expect the government to custom-design an insurance policy especially for you.

      AS for the notion the rest of us will pay for your medical care.. . I’m afraid you are mistaken.

      IN the U.S., a hospital, doctor or ER is under no obligation to treat you if you can’t pay.

      If you go into an ER with a runny nose, chances are you will be turned away (and directed to a community health center)

      If you go into an ER and are seriously ill that law requires only that the hospital “stabilize you” which is defined as putting you back in shape so that you can walk out the ER door–even if on crutches. This may mean giving you pain-killers, something to reduce a fever,
      or bring you around if you are unconscious. .

      But even if you have cancer, you will Not receive surgery. (Surgeons don’t take IOU’s)
      Dr. Atul Gawande has written about cancer patients who die because they don’t have insurance.
      Neither he nor other doctors can do anything about this.

      You might be lucky enough to find a hospital that has a charity fund for very sick uninsured patients.

      But these days, the government is no longer paying hospitals extra to help cover the cost of caring for the uninsured.

      I can only hope you stay healthy until you turn 65 and qualify for Medicare.