Smoking insurance costsLast week, Dallas County in Texas joined the growing ranks of employers that charge employees who smoke a higher monthly health insurance premium than employees who don't light up. Beginning Jan. 1, smokers employed by the county will pay an additional $50 per month per person for not only the employee, but also any family member who smokes and is covered by the county's health insurance plan. The county estimates that this "non-smokers' discount" will reduce its medical costs by $500,000 as early as next year.

The idea of increasing insurance premiums on smokers has been around since the 1980s, when the National Association of Insurance Commissioners, the standard-setting organization representing the chief insurance regulators from the 50 states, calculated that roughly 60% to 80% of all of the health care expenses incurred in the United States were attributable to things that people could potentially control, such as failing to wear a seat belt, engaging in unsafe sex, ingesting drugs or alcohol, driving drunk, overeating or under-exercising, and smoking. Given that only some portion of the population was involved in these activities, but that everyone was essentially picking up the tab for the associated medical care, the NAIC wondered if it made sense to require people who made less healthy choices to pay more than those who didn't.

To support this idea, researchers considered the standards around life insurance. By the 1980s, smokers were already paying more for life insurance than their nonsmoking counterparts. Why not apply that to health insurance, so long as the increased rates were only employed under appropriate conditions?

Roughly 20% of Americans smoke. "If you look at the number of people who are smokers," argues John Banzhaf, a professor of public interest law at George Washington University Law School and also the retired founder of the nonprofit antismoking organization Action on Smoking and Health, "versus the great majority who aren't, it's much fairer to put the costs on the backs of those who cause them rather than on the backs of the great majority who don't smoke."

The Price We All Pay

The Centers for Disease Control and Prevention estimate that smoking costs the U.S. nearly $200 billion annually, and that an employee who smokes costs the employer 18% more than a nonsmoker. It's facts like these that Banzhaf and other supporters point to when asserting that a tiered premium structure is a reasonable way to hold Americans accountable for their actions.

According to ASH
, "Such a smoker surcharge would be consistent with President Obama's recent remarks [that] 'we've got to have the American people doing something about their own [health] care.' It would also put into practice the policy of HHS Secretary Kathleen Sebelius, [that] 'personal responsibility extends to lifestyle; that in order to have a healthier America, a more productive America, we need to make some basic changes.' ... If adults should have the choice
whether or not to smoke, it's high time they be required to accept at least some personal responsibility for the financial and other consequences of their choice to others."

The idea has gained traction. Today, almost a dozen state governments charge higher health insurance premiums to employees who smoke. Companies are also jumping aboard. PepsiCo (PEP), Macy's (M) and Gannett (GCI) charge smokers a higher premium, while others, including Humana (HUM), Union Pacific (UNP) and Scotts Miracle-Gro (SMG) simply outright refuse to hire smokers.

But for every supporter, there is a detractor. "Right now, there is not enough evidence to support increasing the cost of health insurance, in terms of its impact on smokers quitting," says Dr. Kurt M. Ribisl, associate professor at the UNC Gillings School of Global Public Health. "I am concerned when cities and states pursue untested and punitive approaches when they have not yet done what we already know is effective like raising cigarette taxes, and banning smoking in all workplaces, restaurants and bars."

Ribisl is also concerned that "raising the cost of health insurance may get some smokers to quit, but it may backfire by making health insurance more costly and less available. This can push smokers out of the health care system when they need easy access to quit-smoking medications and doctors who will tell them to quit."

Tiered Premiums Feel Fair ... If You Don't Smoke

Despite these concerns, the Obama administration has included the tiered health care premiums in its new health care legislation, allowing employers to raise smokers' health care costs by over 100%. Supporters like Banzhaf argue that the increased fees could not only motivate smokers to quit, but will also generate revenue for the federal government without plunging into the onerous challenge of raising taxes.

Which sounds great. But to Ribisl's point, there are other strategies known to work while this one remains unproven. We need data to confirm that such a rate increase would affect change.

The other complicating factor here remains the question of the degree to which smoking is a behavior individuals can control. On the surface, it looks like one: We aren't born smoking. Rather, people opt to pick up that first cigarette. And this is the argument behind the tiered premiums. If you choose to engage in this behavior, you should take financial responsibility for it. In a similar way, the premiums on car insurance, and fire insurance on our homes, vary depending on whether or not we chose to take certain precautions.

But smoking is addictive, which is why so many who people try to quit fail. That very addictiveness muddies the waters around the idea that it's reasonable to penalize people for the behavior -- for actions they may no longer be able to effectively control. For similar reasons, many Americans are uncomfortable with the idea of applying a tiered insurance premium system based on weight. We recognize that obesity isn't just about eating less, but also about a person's metabolism and genes, areas over which we don't have much control.

I believe strongly in personal responsibility, but I also know that not everyone has the same intrinsic ability to overcome an addictive habit. It's not simply about willpower. It may also be about the person's physical response. Either way, I know this: I don't smoke. And I wish others wouldn't -- for my sake, but also for theirs.

Loren Berlin is a reporter with the AOL Huffington Post Media Group. She can be reached at, on Twitter at @LorenBerlin, and on Facebook.

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OK you know what here is a fact most people who quite smoking become fat so does that mean that your damned if you do and damned if you don't

April 01 2012 at 1:36 AM Report abuse rate up rate down Reply

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January 12 2012 at 3:59 AM Report abuse rate up rate down Reply
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September 17 2011 at 11:01 AM Report abuse rate up rate down Reply

It's tough to lose's tough to stop smoking. Yes, it is, tough, but it can be done. I know, I did it. It's willpower. It's hard, but it can be done. I did not go to some expensive weight loss plan or turn to drugs to quit smoking; I just quit cold turkey; substitute bad habits with good habits.

Why not have an insurance company reward for good behavior? This is not taking away from people with bad behavior; they would not get a price break. I believe this is fair. I sure could use a price break, as I'm at the age where my insurance is higher and I feel it's not fair since i don't take drugs (meds) and only go for yearly check ups. So I think the insurance company is not fair to me.

September 15 2011 at 10:24 PM Report abuse +1 rate up rate down Reply

Since smokers supposedly die earlier than their non smoking brothern they should pay less for medical insurance. Riddle me this, the percentage of smokers who die...100%. The percentage of non smokers who die...100%. Hmmmm

September 15 2011 at 1:54 AM Report abuse +1 rate up rate down Reply

This is ridiculous. Smokers should be charged more than drinkers? drug addicts? obese people? people who ride motorcycles without helmets? people who don't wear seat belts? people who text while driving? Who does these studies? ANTI-smokers? I smoke & in the past year I've only been to the doctor once & that was to adjust my diabetes meds. It had nothing to do with smoking, it's hereditary. I know that smoking is dangerous to people's health, but no more dangerous than those things I've mentioned above. My Sister, who lives by herself & doesn't smoke has been to the doctor 16 times this year. Again, I agree that smoking is dangerous, but stop blaming the smokers for everything that goes wrong in this world. And on a related matter, they made the gambling boats in IL non smoking & their profits went down bigtime. Anti-smokers blame the economy, but the gambling boats in Wisconsin & Indiana where smoking is permitted, are thriving. That's because the smokers in IL go there. I go there. I would rather drive an hour, relax & be comfortable than stay here, unable to enjoy myself. I used to play bingo 3 times a week. No smoking, now I go about once every 3 months. And the non-smokers did not live up to their end of the bargain of increasing revenue lost in bars & restaurants where smoking isn't allowed. Anti-smokers have a block in their head & only see what they want to see. I would like to see honest stats compiled by open-minded people. If someone who smokes is being treated for a broken leg, you cannot count this as a smoking related medical stat. If a smoker dies from cirosis of the liver, that should not be counted as a smoking incidence. And regarding the "pipe dream" of smoker's quitting because of having to pay bigger premiums is not realistic. The money will just come from somewhere else in the budget. Get real people!

September 15 2011 at 12:34 AM Report abuse +2 rate up rate down Reply

drinkers should also pay more, for the damage they are causing to there bodies

September 14 2011 at 11:58 PM Report abuse +1 rate up rate down Reply

oh wait, wine has health benefits- make teetotalers pay more too.

September 14 2011 at 11:01 PM Report abuse -1 rate up rate down Reply

lol, maybe athletes should pay more too. tons of chronic knee problems, joint problems. had a pal who did tae kwon do and had had 3? knee surgeries by her mid twenties. still has pain. ride horses? you fall off. you should pay more too. allergies? well, you choose to live in this area. more insurance premiums for you too. the war on fat people has already begun. never mind studies show a certain amount of overweight actually has health benefits. so maybe make folks gain weight or pay more?

September 14 2011 at 10:58 PM Report abuse rate up rate down Reply

Duh... Of course smokers should pay more. They have put themselves in a group with quantifiable higher risk. This is they way insurance works. Car owners pay different rates based on crime statistics by zip code. If your argument is that drinkers and the obese should pay more, I concur if the data proves they should. Also, some of the people making comments here are blurring the distinction between insurance cost and taxes. Insurance companies are in business to break even at a minimum, and are not required to take on everyone as a customer. This makes them way different than a taxing authority.

September 14 2011 at 10:52 PM Report abuse -2 rate up rate down Reply