No Patient is an Island in Arizona's Medicaid

A recent news article reported that Arizona's governor, Jan Brewer, has proposed a $50 dollar fee to the state's Medicaid recipients if they smoke, or if they are obese and don't succeed in following doctor's orders to lose weight or stop smoking.  Private insurance plans are already using these techniques, but government sponsored programs have not previously used dollar incentives to control behavior. The Governor has proposed these changes to help cover the soaring costs of the state's Medicaid program. Medicaid is one of two programs, along with education, that rank as states' top two expenses.

While our nation moves further into a national health care coverage, the forces of inter-societal tensions will continue to rise as we share the burdens of our brothers and sisters illnesses, some of which we will inevitably view to be a result of irresponsible behavior. This proposed $50 fee is an example of the growing desire to force those undisciplined individuals among us, who raise the cost of everyone's health care coverage, to cover some of those costs themselves. But where should we draw those lines? What if the person can't help himself? Should smokers pay more to a national health system? How about heroin addicts? I could go on...

I once encountered  a young woman (around 40+) in my medical office applying for disability because of vascular disease. She had previously had major surgery for an occluded (closed) major artery in her abdomen, and had been told to stop smoking because it contributed to her vascular disease (good evidence supports this idea). When she reported that she was still smoking, I explained that she should not ask me to help her apply for disability coverage because I felt it was wrong for her to ask others to give her money when she was doing something to "cause" her disability. She never came back to my office again. Was I right? I think so, and the $50 dollar fee is just a governmental example of my individual censure of this patient.

In the health insurance arena, "no man is an island" seems to certainly apply for the "sins" of each of us end up costing everyone, and because of the high costs of medical care those "costing" the system will likely generate an amount of  subtle public disdain. We all understand that some illness is not, as far as we know, related to any "sinning." The child with a kidney tumor, the elderly adult with a brain tumor, the auto accident caused by  someone else, again, I could go on. Is it fair to have these persons pay more because of an illness that they did not create themselves? I think not.

But then there is the self-created illness. Very likely lung cancer, and certainly emphysema, sub acute bacterial endocarditis in an addict (from dirty needles), these are self induced, and clearly the result of  abhorrent behavior. But when I think about it, what of the accident while driving a motorcycle? I happen to ride one for recreation. Some folks might say this is dangerous behavior, and the individual should pay more for medical care--some insurance companies, I have heard,  won't cover motorcycle accidents. That might seem clear to some people, but now lets take rock climbing (something I have no interest in). If someone falls, who should pay? When I think about it, the dividing line between risky and responsible behavior becomes vague, the deeper we analyze. It almost seems that one person's risky behavior is another person's recreation.

The purpose of insurance is, by the way, to have a big enough group, so the costs are spread around equally. Those taking the "higher risks", ostensibly seem to be all of us. Who doesn't climb a ladder, or speed in their car, or eat too much butter (me), or a million other "dangerous" behaviors. I don't think we can separate any one kind of  behavior as dangerous, because much of what we do is dangerous. Let's face it, living  is dangerous, and we all contribute to the costs of medical care. So as for charging extra to smokers, or those who eat too much, I'm not convinced it's fair. Governor Brewer, I'd reconsider your decision.

The Smoker's Choice: addiction

Apparently, there was a recent settlement for 8 million dollars in another "smokers" case. "They made me do it!" The plaintiff was the wife of a smoker who died at age 55 after years of smoking- he was ADDICTED. He died in 1997, at the age of 55. How long does it take for someone to hear the message? Smoking causes disease and death.

I used to smoke myself, and I knew in 1970, that smoking was dangerous for my health. I used to joke that the cigarettes I smoked were keeping the cancer cells quiet, and if I stopped, they would wake up and kill me. The above case is just another nail in the coffin of accepting personal responsibility for our behavior.

As a thoracic and vascular surgeon, I have thirty years of experience watching my patients smoke and struggle to stop. I have heard all the excuses in the world, "I've smoked for 50 years" and, "I'm addicted" are the most common. It's the "I'm addicted" that deserves further comment.

I think the people who make the "products" to help smokers stop want them to believe they are ADDICTED. Believing you are addicted means that you cannot stop WITHOUT buying their product to stop. That is what they want smokers to believe because it means money for them, but what they do not want smokers to consider is that addiction comes in different flavors. Their are addictions to narcotics, or alcohol, and these are serious. If you stop these drugs suddenly, you can die. Seizures, vomiting, and diarrhea are the consequences. But smoking is a special type of addiction that I call a "situational addiction."


As a previous smoker, I know what a situational addiction is. It's one that comes on under certain situations: up in the morning, read the newspaper, a cup of coffee, and a cigarette; an important telephone conversation and a cigarette; after dinner, a cup of coffee and a cigarette. All of these situations NEED a cigarette. I used to get up in the middle of the night, think about a problem that was bothering me, and have a cigarette. When I finally quit, it was the SITUATIONS that I had to deal with to stay away from cigs.

The most common reason someone who has quit goes back, is that something happens that upsets them, and they say," I need a cigarette." This behavior is not a physical addition, as alcohol or narcotics are, this is a situational addiction. This type of addition cannot be handled with medicines or patches, or hypnosis, or needles. It can only be managed with reasoning and attitude, and understanding.

Simply being aware of this distinction can help the smoker understand and deal with the urge to smoke. Change in one's situation can help relieve the stress and the desire for another smoke.

When I quit, I was nervous for about three days. By then, all the nicotine (the "addictive" substance) is gone from the body. That's when an understanding of the situational part of the "addiction" becomes important. I actually wrote the Attorney General about this about one year ago; he never answered.

Success in quiting smoking is as dependent on being aware of the situational part of this process as it is using a patch or other devices to control the urge. I believe the reason so many of these devices fail is because of a misunderstanding of the causes of this addiction. Good luck.

James P. Weaver, M.D.,FACS