Should Smokers Have a  Right to Medicare Health Insurance?

D. John Doyle MD PhD

April 2004

djdoyle@hotmail.com

Tobacco is a legal product and smoking it is a legal practice. Yet it is understood by all to be unhealthy and a cause of / contributing factor to several diseases leading to disability and death. This note discusses whether the life-long smoker's right to Medicare health insurance to cover the treatment of lung cancer should be forfeited because of this self-destructive behavior. 

According to the World Health Organization one out of every two long-term smokers will ultimately be killed by tobacco [1]. They note that “in developed countries, half will be killed in old age, after age seventy, but the other half will be killed in middle age, before age seventy, and those who die from smoking before age seventy will lose more than 20 years of life expectancy”.  In the USA, a 1998 study by Leonard Miller, professor of social welfare at the University of California Berkeley and Dorothy Rice, professor emeritus of health economics at the UCSF School of Nursing found that “smoking-related Medicaid costs amount to $12.9 billion per year, or $322 billion in 25 years without inflation”, a figure that they noted “does not include the financial impact of cigarette smoking on Medicare or private insurance companies” [2].

About 75% of Americans do not smoke, yet everyone pays for the cost of treating tobacco-related illnesses via higher insurance premiums and taxes. Many people argue that it is not fair that non-smokers have to pay many billions of dollars in health insurance premiums and taxes for the medical treatment of smokers. Given the well-established link between long-term tobacco use and lung cancer, this has lead some individuals to suggest that life-long smokers should be denied Medicare or Medicaid health insurance coverage for the treatment of lung cancer.

However, I would suggest that such a policy is both impractical and unethical. Let me explain.

First, while there is no doubt that health care costs are higher for smokers, the extra health care costs to Medicare and Medicaid associated with smoking can be recovered simply by increasing the price of cigarettes. This would be a particularly effective alternative to denying Medicare services to smokers, since there is strong data to suggest that raising the cost of cigarettes is one of the most effective ways of reducing consumption.

Secondly, tobacco smoking is hardly the only form of self-destructive behavior. Other self-destructive practices that one might focus one include the following:

•excessive alcohol consumption

•not wearing seatbelts while driving

•participation in unsafe sexual practices

•excessive food consumption leading to morbid obesity

•use of dangerous recreational drugs such as cocaine or heroin

•participation in dangerous sports without sufficient attention to                    safety issues

In the interests of fairness, if one were to deny Medicare services to smokers, it would also be necessary to deny Medicare services to individuals who sustain clinical insults as a result of other self-destructive behavior. It should be apparent that this would be a logistical nightmare.

Third, if life-long smokers on Medicare health insurance should be denied coverage for the treatment of lung cancer, they should also be denied coverage for other diseases strongly linked to smoking: coronary heart disease, cerebrovascular disease, peripheral vascular disease, emphysema, chronic obstructive pulmonary disease, bladder cancer, and even age-related macular degeneration (AMD), a leading cause of blindness.

Fourth, the US government has not made a concerted effort to reduce tobacco use. Industry commentators often point out that there is an incestuous relationship between the tobacco industry and US government. While the idea of regulating tobacco use and creating a "smoke-free" society remains a popular dream in Washington, the reality is that the federal government and the 50 states eagerly consume a steady flow of sin taxes generated by the sale and consumption of tobacco products. Furthermore, and most amazingly, Washington continues to subsidize the growth of tobacco. I would suggest that the federal government should clean up its own house first before implementing draconian Medicare policies of the nature suggested.

Fifth, there are many causes of lung cancer besides tobacco smoking, and some forms of lung cancer (e.g. small cell cancer) are not related to smoking at all. Radon exposure, exposure to asbestos, and even dietary factors may account for many cases of lung cancer. In fact, the only form of lung cancer that is unequivocally linked to smoking is squamous cell carcinoma.

Finally, medicine has a humane tradition of being nonjudgmental and caring for all regardless of social worth or social standing. Public policy should reflect this. I would suggest that setting into place a policy whereby a life-long smoker's access to Medicare for the treatment of lung cancer should be forfeited is inhumane in the extreme. Such action says to the patient that he or she is unworthy of our clinical attention, and is in clear violation of the principle of beneficence.

References

[1] TOBACCO – HEALTH FACTS. WHO Fact Sheet No 221. April 1999. http://www.who.int/inf-fs/en/fact221.html

[2] http://www.ucsf.edu/daybreak/1998/03/309_cig.htm