Do You Smoke? Are You Morbidly Obese? No Surgery for You!

A shift in the who-should-pay-for-healthcare debate occurs across the pond.

Posted Jan 24, 2018

Your next-door neighbor likes to drink. And so one night, in a drunken stupor, he drops his lit cigarette on the carpet. Forty-five minutes later, he is standing outside staring at the burnt remnants of his home.

The next afternoon, he’s at your door, bloody Mary in hand, asking you to help pay for the reconstruction of his new home.

I imagine that the majority of us would refuse (perhaps after an incredulous laugh).  After all, his poor behavioral choices led to the horrible consequences. Why should we pay to address the clear and predictable results of his voluntary behaviors?

Is this an appropriate analogy in the debate over America’s unsustainable healthcare costs?

Everyone, everyone, knows that smoking is horrible for your health: cancer; heart disease; stroke; chronic obstructive pulmonary disease (COPD); and much more. And that cigarette smoking is the leading cause of death in the U.S. (nearly 20%).  Nor can we honestly debate whether smoking is (at least initially) an individual behavioral choice.

Everyone, everyone, knows that obesity is horrible for your health: type 2 diabetes (virtually epidemic today), with its significantly increased risks of heart disease; kidney failure; stroke; high blood pressure; and other ailments. And certainly the causes of obesity (dietary and activity related) represent (at least initially) individual behavioral choices.

Are morbidly obese individuals and smokers analogous to the drunken neighbor whose former home is now an ash heap? Why should the general taxpayer population help pay for the health problems that predictably result from their poor behavioral decisions? Aren’t the smokers and the obese solely accountable for the known health risks resulting from their voluntary actions?

Or is the analogy unfair? Perhaps these unhealthy behavioral choices and activities aren’t truly “choices” at all. For many, don’t these behaviors which cause damage as an adult first take root in the child? The child whose family eats an unhealthy diet, rarely exercises, and often includes overweight members? The child whose family members and/or friends smoke?  The child in whose environment such activities are “the norm?” Thus aren’t these poor behavioral “choices” made by the young (often unconsciously) with the approval (tacit or direct) of family members, friends, and others within the child’s social network? That is, perhaps these choices are not really choices at all. Nor are these unhealthy habits easy to change, even for an adult who is clearly aware of the dangers, even for those who wish to quit smoking or to lose weight. If so, then aren’t smokers and the obese as deserving of the taxpayers’ healthcare dollars as a person requiring surgery for a gallstone attack, that is, “through no fault of their own?”

These are the two extremes on the who-should-pay-for-healthcare philosophical spectrum; but wherever you fall, the debate can no longer hide from financial reality.

And this is not just an American problem.

In Great Britain, the who-should-pay debate recently slammed into the nation’s financial healthcare crisis reality. (I have spent a great deal of time in the U.K. and am often surprised by how different many Americans’ favorable view of the public National Health System (NHS) contrasts with many Brits’ view.) And so it was that last September, several NHS Commissioning Groups (“general practices which come together…to commission the best services for their patients and population”) created a requirement that “morbidly obese patients have to lose a specified amount of weight prior to becoming eligible for any type of non-urgent surgical procedure,” and that “smokers stop smoking for at least six weeks prior to being placed on the waiting list for all non-urgent surgical procedures.”

In other words, if you’re too fat, or if you smoke, the British taxpayers (via the NHS) in these communities would no longer pay for your elective operations. And there is a significant concern (or hope, depending on your ideology) that such restrictive approaches to healthcare cost control will expand across the financially challenged NHS.

A couple of important details here. First, we’re talking only about elective operations (that is, procedures which are not required to save or prolong life or limb). In fact initially, the focus is on limiting hip and knee replacements. The logic is two-fold:  morbidly obese patients and smokers have significantly greater rates of (costly) surgical complications (including life-threatening); and there is a belief that these two groups of patients frequently demonstrate less successful post-surgical outcomes. Second, the restrictions allow for the elective procedure should the morbidly obese patient lose a specified amount of weight or the smoker cease cigarette use for at least six weeks prior to the procedure. Still, the intent is clear:  British taxpayers will not pay for non-emergent, non-urgent procedures to address quality-of-life issues in groups of patients whose individual behavioral choices significantly increase the risk (and thus the cost) of the treatment.

There has been significant pushback in the U.K., and the newly proposed restrictions are now under review. That said, the NHS already has numerous (although less draconian) patient weight-based rules regarding referrals for certain surgical procedures. 

In fact, the same is true here in the U.S. Restrictions on taxpayer-supported medical care (Medicare, Medicaid, and state-sponsored programs) already exist. For example, “Cosmetic procedures and/or surgery are statutorily excluded by Medicare” unless the treatment is provided to address a very short list of indications (such as improving a functional physical limitation or for post-mastectomy breast reconstruction). Thus, our federal and state governments have already decided that American taxpayers will not cover the costs of surgery for patients seeking cosmetic treatments.  (Note that for some, cosmetic treatment dramatically improves confidence and, as a result, quality of life.)

In other words, we’ve already joined the Brits in stepping on to the slippery slope…the only questions are how far down and how fast we’re going to slide. And as with Britain, the U.S. is in the midst of a massive, ongoing financial healthcare crisis (the viability of Medicare? ObamaCare? the federal debt!). Everyone, everyone, agrees that healthcare costs must be reined in.

One way or another, more and more aggressive restrictions and penalties are likely coming. ObamaCare penalizes provider institutions for failing to meet numerous value-based care standards. But as hospital leaders and clinicians are quick to point out, the vast majority of healthcare costs are related to individual patient choices, activities, and behaviors outside of the hospital (medication compliance; diet; physical activities). Many would argue that the restrictive “personal accountability” approach being considered by the NHS is a good place to start. Others are horrified by such an ideology, viewing it as compassionless, punitive, and antithetical to their belief in “healthcare as a right.”

So, considering your wallet and your own personal choices and behaviors, is your neighbor a homeless drunk or a societal victim with healthcare needs?