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Health insurance coverage for nicotine dependence treatment

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Last night I went to see the Michael Moore movie “SiCKO” which is an expose of the problems with the U.S. healthcare system, focusing particularly on the problems with health insurance and so-called “Health Maintenance Organizations (HMOs)”. No matter what you think of Michael Moore, if you have any interest at all in your health or that of your family, and particularly if you have any interest in this nation’s health, then you should definitely see this movie.

The movie points out some of the worst aspects of the health insurance system and then compares it to the situation in countries like Canada, the UK, Cuba and France. As someone who has been both a patient and a provider in the UK and US healthcare systems I have to say I found the portrayal in the movie to be very accurate. The United States is a great country with tremendous wealth both financially and in terms of the resilience and hard work of its people. But to my mind its healthcare system is nothing short of a national disgrace. There are many areas of business in which the free market works best, but healthcare is just not one of them. A clear example of this is the existence of hundreds of doctors and other professionals employed by HMOs basically to devise reasons to deny coverage and save the company money. A number of ex HMO employees in the movie explained that they would receive bonuses based on the proportion of denials of care/coverage the achieved, setting up a bizarre situation where staff are given incentives to provide less care for sick patients.

I suspect that unless you or your family have never been sick, or you are fortunate to have good coverage through your employer, and not to have suffered from one of the numerous illnesses that are not covered, then you won’t need any further evidence from Michael Moore or myself to know that the U.S. system is entirely broken. But you may be living under the false impression that despite its problems, the U.S. system is better than most other comparable places. As the movie shows, citizens in many other (poorer) countries have access to high quality medical care 24-7 at no (or minimal) direct cost. Doctors are able to provide healthcare according to need rather than according to individual ability to pay. Moore’s portrayal is supported by cross-national surveys on the satisfaction of citizens with their health system, in which Canada and the European nations have consistently earned higher marks than has the U.S. system. Part of the problem is that U.S. healthcare is more expensive, it treats patients more intensively (overtreats?), and it is very inefficient. So the very things that a free market is supposed to be good at (achieving lower prices and higher efficiencies via competition) do not work for healthcare. Why is this? Well part of the problem (in my humble opinion) is that some rather dim-witted people have continued to base their design of the system on ideology rather than a careful but common-sense analysis of how healthcare actually works. Take the example of a medium-sized city, - say 100,000 adults with another 100,000 in a 50-mile radius. Such a city will typically have one medium sized hospital, and just about enough medical personnel to cover most (but maybe not all) specialties. The idea of letting the market compete for best value healthcare in that (fairly typical) city is clearly ridiculous. The provider has a monopoly. In some places the health insurance company may also have a virtual monopoly. Add to the mix you as an individual developing a life-threatening illness and you really do not have a situation in which the free market system is likely to work well. So you don’t have many of the most important potential advantages of a market-based system, but you do have the disadvantages of businesses (including the doctors, hospitals, insurance companies etc) seeking to maximize profit. In the end it’s the patient that suffers.

In addition to the disadvantages of the U.S. system described above and shown in the movie, to me there is one very basic thing about the psychology of illness that makes this system bad. If ever there was a time in your life that you really don’t want to have financial worries, it’s when you or a loved one is sick. The system we have in the United States is designed to maximize financial stress whenever we get sick. Everyone in this country, except perhaps the very rich, has to live with the concern that if we are unlucky enough to get a serious illness that is expensive to treat, then everything we have built for our family is at risk, not just because of the illness but because of the cost of getting it treated. In most other comparable countries of the world, the people just have to worry about the illness, not the cost of treating it.

As you may have gathered, this is one of those topics (like global warming) that is much bigger and more important than my specific area of interest: tobacco and health. But I see on a daily basis how the U.S. system does not work well with smoking cessation. Counseling smokers and providing them with an effective smoking cessation medicine is one of the most cost-effective healthcare interventions available. But most healthcare providers cannot get paid by the insurance systems for providing such interventions and most patients cannot get the costs of their treatment covered by their insurance. If you are lucky, your health insurance will pay for your coronary artery bypass operation caused by your smoking, or for your operation and chemotherapy to treat your lung cancer. Most likely this could all have been avoided if your insurance had covered your smoking cessation treatment(s) in the first place. Instead your insurer is employing staff whose job it is to think up ways to deny you coverage: “we don’t cover over-the-counter treatments like the patch”, “we don’t cover preventive interventions”, “you have $200 per year for preventive care, but having your blood pressure measured at your last visit used that up”, “there are no tobacco treatment specialists in our network”, “your policy has a $500 deductible for preventive or behavioral interventions and smoking cessation is valued at $499”, “we don’t have a diagnosis or procedure code for smoking cessation” etc etc…” but we CAN send you a leaflet that tells you how bad smoking is for your health”!

So I’d recommend that you check out the movie and let me know what you think. If you managed to get help to quit smoking provided or paid by your health insurance, I’d love to hear about it. It’s always nice to hear about the times/places where the system works well. When you are considering who to vote for in the forthcoming elections, please check out the detail of their policy on health insurance, and also find out how big a contribution they accepted from (a) Big Pharma (b) Big Managed Care and (c) Big Tobacco. By doing that and voting for candidates who appear likely to do the best job on healthcare, we might get some much-needed change.
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About the Author


MA, MAppSci, PhD

Dr. Jonathan Foulds is an expert in the field of tobacco addiction.

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