Smokers avoid health insurance, not quitting

We all know smokers face more health risks than nonsmokers. Shouldn’t they pay more for health insurance? And wouldn’t a higher rate persuade some smokers to quit? That’s the theory behind Obamacare’s surcharge on tobacco use. But it’s not working out in practice, Yale researchers have found.

The Affordable Care Act requires plans bought on health insurance exchanges to cover help for quitting smoking. It also lets states charge tobacco users up to 50 percent more. A team led by Assistant Professor of Public Health Abigail Friedman looked at 2011–2014 federal data to examine the results—comparing smokers’ insurance coverage, and checking smokers’ rates of quitting, both before and during the first year the exchanges were up and running. The study appeared in Health Affairs.

The team found a lower likelihood of enrollment—as much as 11.6 percent—for smokers who faced surcharges versus smokers who didn’t. The higher the surcharge, the bigger the dampening effect. And smokers under 40 were nearly 20 percent less likely to be insured. That’s problematic because the young have fewer health problems and lower healthcare costs, so their participation is needed.

As for quitting rates, smokers charged medium or high surcharges were no more likely to quit than those not surcharged. Surprisingly, though, those faced with a low surcharge were less likely to quit. It’s not yet clear why. It’s possible, the researchers write, “that putting a price on bad behaviors can alleviate the guilt of engaging in them, which has an unexpected effect: the behaviors increase.”