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The Law of Unintended Consequences

As a firm believer in the Law of Unintended Consequences (LoUC), it immediately came to mind when I read a post by Dan Diamond over at the Health Care Blog, About Time? Smokers Face Tough New Rules Under Obamacare which details a little known provision of the PPACA (Patient Protection and Affordable Care Act aka Obamacare). Go give it a read because this a place where the LoUC could wreak all sorts of havoc… especially to those of us who are diabetic.

Basically, the provision says that smokers can automatically be assessed a 50% surcharge on their health insurance premiums starting in 2014.  ** believe me, I have some very strong opinions about tobacco and taxes in this country but that would that would be a huge aside, maybe another day 

You’re probably saying “Uh… ok they chose to smoke but I didn’t choose to get diabetes so why should I worry about this?”

And that is a correct analysis… up to a point.  Diabetes is one of the few conditions on the planet, besides STDs, where the patient is often blamed for having it.  Often the patient themselves believe it is their fault.  So, if perceived as our own fault, why shouldn’t we expect a surcharge as well?

Oh and let’s take it further to the dreaded word “non-compliant”.  What if we don’t get the expected benefits from our treatment?  The assumption usually is that we’re not doing something we’re supposed to, will there be a surcharge for that?

Exercise is good for us, if we don’t exercise will there be one for that as well?  What is enough exercise?

How about obesity?  Lord knows I could stand to lose two or three dozen pounds…

Diabetes and obesity?  Even though most of the research is showing that obesity is often the first visual symptom of the most common types of diabetes, most still see obesity as the cause.  ** quick reminder that correlation does not equal causation.  In addition to that, there are conditions that make it difficult, if not impossible, to lose weight.

I chose to go skiing and broke my leg, I chose to drive my car and became injured in wreck.  OK, those last two are pretty ludicrous but when you look at a system designed around making money those earlier examples start to look pretty reasonable.

Could the LoUC as applied here result in direct “intervention” into our treatment regimens?  Who would do the “intervening”?

How about mental heath, again another stigmatized condition where often people don’t get help because of that stigma and sometimes can’t get help because of a lack of services and/or money.  Unless you go to jail that is.  Will I be penalized because I have clinical depression of the major recurrent kind?  Mental health issues are again often viewed as being the patient’s fault some how.

I’m not debating if there should be a surcharge to smokers or not. I am asking if this will set a precedent?

© 2013 Scott Strange, Strangely Diabetic and http://StrangelyDiabetic.com

  • http://scottsdiabetes.com/ Scott K. Johnson

    Sure gives a lot to think about, that’s for sure.

    I don’t know if I’m comfortable with the precedence this sets.

    • http://strangelydiabetic.com Scott Strange

      I know Scott… It totally goes against the concept of “universal
      healthcare”. To me this makes it pretty obvious that it’s basically the
      same system, just wrapped up in new legislation. It’s even more obvious
      to me that we need “health insurance reform”.

  • http://strangelydiabetic.com Scott Strange

    I know Scott… It totally goes against the concept of “universal healthcare”. To me this makes it pretty obvious that it’s basically the same system, just wrapped up in new legislation. It’s even more obvious to me that we need “health insurance reform”.

  • Harry

    people need to be incented to adopt healthy lifestyle habits. Left to their own, people will engage in a myriad of self harmful behavior.
    The issue isn’t that a person’s right to engage in self harmful behavior needs to be restricted, but rather when society has to bear the cost of the consequences we may, as a society, decide to impose restrictions. Since this is a very controversial topic, we tend to only consider it when the behavior we are talking about (smoking, obesity, etc.) has an overwhelming impact on the common good.
    That is why activities like skiing, even though it might result in injury, aren’t considered, they just don’t rise to the level of harming society. If we faced a condition where 50% of healthcare costs were caused by ski accidents, I’m sure the conversation would change.
    The vast majority of people have a weight problem because of personal choice. It’s not helpful that our society has made empty calories cheap and plentiful. Ultimately a rational person operating in their own interests would come to the conclusion that they can live better if they lose the weight, unfortunately few people tend to come to that conclusion.
    There is a lot of science that shows that obesity is a risk factor for diabetes, and the underlying mechanism is being understood. It’s clear that being morbidly obese is a big problem and will need to be addressed if we are going to reign in our health care costs.

    • http://strangelydiabetic.com Scott Strange

      Thanks for replying but I disagree with your points and here’s why.

      1)Tobacco has had large tax increases all in the “hopes” of reducing
      smoking. This provision is exactly the same thing. The first hasn’t
      worked very effectively and I doubt that this one will either. It will
      simply be another reason for people to not adopt the mandated coverage.
      The government likes to tax things that people “need”, or in this case
      are addicted to. It helps provide a revenue stream. Take a close look
      at your phone bill and see how much you are paying on it in taxes and
      other “fees”. The Clinton Administration sued the tobacco industry and
      won $168 billion to help states cover the cost of smoking related
      illnesses and prevention campaigns. If you want to start, just start
      mind you, to get an idea of what the health of Americans is worth to
      their elected leaders, calculate the loss of tax revenue if tobacco
      products were outlawed.

      2)Tobacco is a confirmed carcinogen and is still on the market. If
      society wants to stop the costs related to smoking it should outlaw
      tobacco instead of blaming the addict. There’s an impact on the “common
      good” for you.

      3)Is obesity a personal choice or a result of not being able to
      afford to make healthy choices at the grocery store? Maybe a little of
      both. Again, if society wants to “help” it should make sure that
      affordable, healthy food choices are available. In many populations,
      they are simply not affordable or available.

      4) I understand that there is a correlation between weight and
      diabetes (Type 2), as I stated in the post, but I also personally know
      Type 2 diabetes that are not obese. Once again, correlation does not
      equal causation, and studies have also shown (The Whitehall II Study
      pops to mind) that the cellular changes that lead to insulin resistance
      can be detected years before a person is diagnosed as diabetic which
      lends itself to the idea that obesity is a symptom in most cases (I
      believe there are a couple of “sub-types” of Type 2 where that is not
      the case).

  • http://strangelydiabetic.com Scott Strange

    Hi Harry,

    Thanks for replying but I disagree with your points and here’s why.

    1)Tobacco has had large tax increases all in the “hopes” of reducing smoking. This provision is exactly the same thing. The first hasn’t worked very effectively and I doubt that this one will either. It will simply be another reason for people to not adopt the mandated coverage. The government likes to tax things that people “need”, or in this case are addicted to. It helps provide a revenue stream. Take a close look at your phone bill and see how much you are paying on it in taxes and other “fees”. The Clinton Administration sued the tobacco industry and won $168 billion to help states cover the cost of smoking related illnesses and prevention campaigns. If you want to start, just start mind you, to get an idea of what the health of Americans is worth to their elected leaders, calculate the loss of tax revenue if tobacco products were outlawed.

    2)Tobacco is a confirmed carcinogen and is still on the market. If society wants to stop the costs related to smoking it should outlaw tobacco instead of blaming the addict. There’s an impact on the “common good” for you.

    3)Is obesity a personal choice or a result of not being able to afford to make healthy choices at the grocery store? Maybe a little of both. Again, if society wants to “help” it should make sure that affordable, healthy food choices are available. In many populations, they are simply not affordable or available.

    4) I understand that there is a correlation between weight and diabetes (Type 2), as I stated in the post, but I also personally know Type 2 diabetes that are not obese. Once again, correlation does not equal causation, and studies have also shown (The Whitehall II Study pops to mind) that the cellular changes that lead to insulin resistance can be detected years before a person is diagnosed as diabetic which lends itself to the idea that obesity is a symptom in most cases (I believe there are a couple of “sub-types” of Type 2 where that is not the case).

  • http://www.sstrumello.com Scott S

    No doubt, the local coverage in your part of the country paints a very different picture of the Patient Protection and Affordable Care Act than in other parts of the country (the whole red state vs. blue state thing), and while the goals of the provisions you cite are to encourage some personal responsibility, most people aren’t impacted because they rely on their employers to pay for their healthcare insurance so the cost decisions aren’t really even considered.

    Most of the provisions of Obamacare, incidentally, were originally from GOP lawmakers, which is one reasons many hate the fact that its now law. However, the reality is that healthcare insurance companies cannot simply raise rates 50% on a group of people, it must be approved by the U.S. Department of Health and Human Services, and the Secretary of that happens to be former Kansas Governor Kathleen Sebelius. Down the road, that could change, but for the next 4 years, I suspect most insurance companies will be kept on a pretty tight leash.

    At the same time, this is already going on in the marketplace with tiered pricing provisions, co-pays and various obligatory “disease management” programs (although research has shown pretty conclusively those programs do not work). The only exception is before the Patient Protection and Affordable Care Act, patients with diabetes (or any other pre-existing condition) were ineligible to obtain coverage at any price.

    I look at it this way: the free market for healthcare insurance could not be trusted to behave in a manner that was not overtly discriminatory.

    An unrelated example of the free markets gone wild was the mortgage crisis which is well-documented, but another was the fact that one of the few bipartisan bills to pass Congress in 2010 was the the Commercial Advertisement Loudness Mitigation (CALM) Act which became effective on Thursday, December 13, 2012.

    The CALM Act re-regulates volume of TV commercials and directed the FCC to come up with enforcement rules prohibiting TV commercials from being louder than the programming. Those rules were dropped in the 1980s, and the industry saw that as a green light to raise the volume of TV commercials. When digital television went into effect, the issue prompted so many complaints to the FCC and lawmakers of every political persuasion were obliged to re-regulate the practice they deregulated 20 years earlier.

    Why do I raise these seemingly unrelated issues?

    The simple fact is that the U.S. healthcare system had become so irresponsibly greedy during the past 30 years, and while provisions of the new healthcare law will no doubt have adjustments that will need to be made, the end result will be more government oversight of an industry that pretty much abused the free markets. As for unintended consequences, we shall see how that pans out.

    • http://strangelydiabetic.com Scott Strange

      Thanks for the comment, Scott… It may surprise you to know that I am pretty libertarian but also believe that some industries are too big and too critical to our infrastructure to be left to a free market model as your own observations about greed indicate.

      Personally, I believe that the PPACA did not go far enough and that we should have set a timetable for a transition to a single payer system by, say, 2030.

      This entire thing makes me uncomfortable simply because there is so much money involved. Money is protected Free Speech and allows industries to wield considerable power when compared to the citizens the government is supposed to protect.

      Another thing in the Act that concerns and upsets me is the limitation on Flexible Spending Accounts, while this will have minimal impact on me, it could have huge impacts on families with special needs children and those families with multiple patients. If you want to itemize, you now need to spend 10% of your adjusted gross on healthcare and then can only deduct amounts above that 10%. This is yet another financial burden on families and could be detrimental to seeking care.

      That word “could” is symbolic to me be it doesn’t seem that anyone can explain everything that this Act will do, imagined or otherwise. As the linked article here demonstrates, we’re just starting to see bits and pieces mentioned as people notice them.

      And you’re right, we’re just gonna have to wait and see

  • Aurthur

    “Thanks for the comment, Scott… It may surprise you to know that I am pretty libertarian but also believe that some industries are too big and too critical to our infrastructure to be left to a free market model as your own observations about greed indicate.

    Personally, I believe that the PPACA did not go far enough and that we should have set a timetable for a transition to a single payer system by, say, 2030.”

    Usually do not go out of my path to step in dog crap, but this steaming pile needs to be pointed out, perhaps with GPS coordinates, so others may gaze upon its breath taking ridiculousness… I know libertarians, and you are no libertarian.

    • http://strangelydiabetic.com Scott Strange

      And that is why I said “pretty libertarian but …”

      • Aurthur

        No offense, but you are not “pretty”, either!

  • Don

    Re: LoUC. If you believe this law will reduce the number of uninsured (as it was intended) you are very wrong. It may very well increase the number of uninsured. Keep in mind, like any law (smoke) the devil is in the details (regulations) or if you wish, mirrors.

    Also, FYI, no country has an exclusive single payer system. this is from an employee benefit consultant with over 40 years of experience.