I had recently been at the hospital to visit a friend and had discovered that hospitals will no longer be paid for any treatment given for a hospital acquired urinary tract infection. That seemed to make perfect sense. Why should a patient have to pay for a problem the hospital caused and then treated? I then also found out that the list of unreimbursed diagnoses was growing monthly, and now included hospital acquired deep venous thromboses (blood clots in the legs or arms) and MRSA (a resistant Staph bacteria) related infections in an uncolonized patient. These are all good ideas to help reduce the burden on the United States healthcare system, but it didn't take a second thought to figure out that it wouldn't be enough to save the system.
On my home I stopped to get gas, and while I was waiting inside I noticed four teenagers drive up. One got out and came inside. He went up to the register and asked for a pack of Marlboros. The cashier asked for ID. The teen replied, "Oh, I don't have it on me. But he knows me," and gestured towards another gas station worker, who did not acknowledge the teen. So the cashier gave him a pack of Marlboros and the teen paid and left. Outside of the disappointment for the blatant disregard of the law and the obvious hazards of smoking, I was struck by the fact that my children are going to have their paychecks garnished to pay for this idiot's nebulizer treatment and hospitalizations for COPD exacerbations and angina in a few decades. Is this fair? No. No it is not fair.
People are always saying that healthcare is getting more and more expensive. Medicare is going to go bankrupt. Employers are going to shift the burden of cost to the employees. And the best solution that people can formulate is to pay healthcare providers less. Now I can understand if healthcare providers are fleecing cystic fibrosis patients or breast cancer patients out of their life savings. That would be just plain wrong. But what about the obese patient that refuses to change his lifestyle even after developing diabetes? What about the smoker who will not quit and develops emphysema or lung cancer or has a heart attack? Do we simply pay the healthcare professionals less for the care they give these patients? We whine that the government needs to pass more laws and set more regulations because more than half of us are obese. And then we complain that the people treating our complications are charging too much. That would be like telling the government to pass laws to reduce cell phone use while driving (which some have done), but then complaining that our mechanics charge too much to repair the dent we got after a fender bender because we weren't paying attention while chatting on the phone. And then, of course, forcing the mechanics to lower fees to even below those adjusted for inflation.
The latest ideas are those that steer or simply default the public into doing the right thing, and making it harder and requiring a more active role to "opt out". This is true for 401k plans. Everything about 401k plans tells you that you should enroll, yet less than 30% of workers did less than ten years ago. But now, employers automatically enroll employees, who then must "opt out" of the 401k plan in order to not save for retirement. So now the majority of workers have a 401k plan and are likely better off for retirement.
So I have a new idea to reduce the cost of healthcare. There will be no insurance coverage for any conditions caused by smoking. Tobacco is the number one cause of mortality in the US. It is responsible for heart disease, lung disease, and several cancers. It is also a plight on the environment, both by its smoke and the butts. Over 90% of all smokers simply drop their cigarette butts on the ground as though it will evaporate like a drop of water. We as a public have generally supported the rising taxes levied on cigarette sales because it is accepted that cigarettes have no redeeming quality to the general public. Cigarette taxes have risen quite a bit over time, and those taxes have paid for a lot public good. There is still more good that can come from cigarettes. Imagine all the money that is spent on healthcare related to consequences of smoking. All those imaging studies--xrays. CT scans, cardiac catheterizations; and all those medicines--plavix, spiriva, nebulizers, portable oxygen; it all costs billions of dollars a year. And that doesn't include open heart surgery, hospitalizations, defibrillators, and office visits. We need to save the system money so that people who are unlikely enough to have health problems can afford health care. We do not need to expend that money on people who do not care about their health. So if you want to save money on your healthcare costs, it behooves you to live cleaner.
This unfortunately is not practical in this day and age. People would simply lie about smoking. You might catch the occasional offender in the act, as you might catch a driver on the phone in New Jersey, but that would be rare. But if someone developed a test for smoking, or for nicotine (as smokeless tobacco is just as bad) that was easy, cheap, and reliable, then there would be hell to pay for not taking care of yourself. Given also what we know about neural and cerebral changes that occur in smokers, scans may also be a possibility in the near future.
Ultimately, a sin tax should be confined to the sinner and not trickle down to the public.
Wednesday, July 23, 2008
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