Physicians as Smoking, Fat Police? In Ariz., They Could Be

June 3, 2011

A plan proposed by Arizona state officials would impose a $50 fee to childless Medicaid recipients who smoke and/or are obese. How would such a rule impact physician practices?

Practically every state in this country is looking for creative ways to finance its Medicaid program in an era of budget cuts. But a radical plan proposed recently by Arizona state officials that would impose a $50 fee to childless Medicaid recipients who smoke and/or are obese is stirring up some controversy. 

It’s no surprise that this type of plan would come under fire for discriminating against the poorest patients who lack financial resources and often the education and motivation needed to maintain a healthy weight or stay cigarette- free. According to the Centers for Disease Control and Prevention, one in four Arizona residents is overweight and nearly half of all Medicaid recipients smoke.

The very thought of a “tax” of sorts on smokers and the overweight comes with a lot of questions, including some that could impact the daily operation of physicians in Arizona and elsewhere if the initiative spreads.

The concept of a fee for bad health behavior isn’t without merit, though, when one considers that smoking-related illnesses and obesity cost taxpayers millions of dollars.

In a Q&A excerpt with the New York Times, Monica Coury, spokeswoman for Arizona’s Medicaid program, attempted to explain some of motives behind such a plan.

In Arizona, said Coury via transcript, “there has been an increase of 30 percent in the number of people on Medicaid and a 34 percent decrease in general fund revenue since 2007. We are one of just a few states that cover childless adults in Medicaid.”

When asked why it’s a good idea to charge people for being overweight and for smoking, Coury noted that complaining about cost without drilling down to what it means “on the individual level” won’t change anything.

“Maricopa County [where Phoenix is located] has started a program among its employees where smokers have to pay $450 more for health insurance than nonsmokers,” Coury stated. “They take a swab to detect nicotine. The bottom line is that there’s plenty of evidence and studies that show there is an undeniable link between smoking and obesity and healthcare costs.”

As Arizona fleshes out this plan, we can think of several issues that need to be addressed should other states follow suit.

For starters, there’s the issue of enforcement. Under terms of the plan, people who are obese or chronically ill, and those who smoke, would need to work with a primary-care physician to develop a plan to help them lose weight and otherwise improve their health, according to news reports. Patients who don't meet specified goals would be required to pay the $50 under the proposal.


How would obesity and smoking be measured, then, in the physician’s office? Would Medicaid patients be forced to step on a scale during a routine checkup? Would using nicotine swab testing be required by physicians for all Medicaid patients? Or would state Medicaid program representatives require testing of all beneficiaries prior to authorizing any care by physicians?

Also, while weighing someone is an easy, objective means to determine whether that person is obese (either they exceed the government-established “obese” BM I of 30 and above or they don’t), determining someone’s smoking status is a little trickier and costlier.

Though there are definite signs that a patient is a smoker, it is difficult to 100 percent determine that a patient is a smoker unless a.) someone sees that patient smoking or b.) the person in question undergoes a nicotine test.

I’m not a physician so I can’t speak to the accuracy of nicotine testing kits, swab or otherwise, or how much they would cost wholesale, but a quick Internet search on the cost of a “nicotine swab test” revealed a price range of about $3 to $5. This raises a few more questions: How would these tests be administered, and who would pay for them? If saving money is the ultimate goal, is spending money on tests just to save money counterproductive?

We look forward to hearing more debate about these issues, and how to tackle Medicaid costs and make fair changes to state healthcare programs.

What do you think? Post your comments below.