Smokers have long known tobacco's risks, among them lung cancer, emphysema and other respiratory problems. But now using tobacco also could mean having to pay up to 50 percent higher health insurance premiums.
A rule under the Affordable Care Act aimed at discouraging tobacco use allows insurers to charge smokers higher premiums because of the additional health costs smokers often incur.
Smoking kills about 443,000 people each year nationwide and costs about $193 billion in medical care and lost productivity, according to the Centers for Disease Control and Prevention.
In Iowa, about 18 percent of Iowans 18 years old and older smoke, costing the state about $1 billion a year in health care costs, according to the Iowa Department of Public Health (IDPH).
The District of Columbia and a handful of states, including California, Massachusetts, Rhode Island and Vermont, have opted out of the so-called smoker surcharge, while several other states have lowered the maximum surcharge allowed.
But the Iowa Insurance Division has allowed all insurers to charge up to 50 percent additional for premiums for consumers who identify themselves as tobacco users, or someone who smokes more than four times a week.
Wellmark Blue Cross and Blue Shield of Iowa's 2014 premiums will be about 15 percent higher for tobacco users than non-tobacco users, said spokeswoman Traci McBee. The insurance company will cover smoking cessation drugs for members who would like to quit.
Wellmark members also will have access to web-based wellness tools and support programs to promote healthier behaviors, including smoking cessation, she said.
CoOportunity Health, a not-for-profit health cooperative in Iowa and Nebraska, will be charging tobacco users premiums that are 49 percent higher, said Cliff Gold, the organization's chief operating officer.
Gold said the company settled on a number so close to the maximum because of its actuaries' analysis of claims.
But if smokers take three 20-minutes courses online during the first two months of enrollment, the surcharge is waived, Gold said. And CoOportunity Health also is offering aids such as nicotine gum and patches to help members stop smoking.
"The enforcement ability of the law is very limited," Gold said, explaining that there is no cap to how many times a self-proclaimed smoker can take the cessation course. "We're hoping to correct that behavior, but at the very least you'll be educated about the hazards."
Opponents to the rule believe the higher rates could further hurt lower-income Americans, who are more likely to smoke. In Iowa, 38.6 percent of Iowans reporting annual incomes under $15,000 reported smoking, while only 9.5 percent of Iowans with incomes over $75,000 reported smoking, according to the IDPH.
That means the federal subsidy aimed at making insurance more affordable for low-income Americans essentially could be canceled out if they smoke.
But even some groups you might expect to favor such a charge are against it.
"We oppose the use of a tobacco surcharge for a variety of reasons," said James Martinez, a spokesman for the American Lung Association Upper Midwest Region, which oversees Iowa as well as Illinois, Indiana, Minnesota, North and South Dakota and Wisconsin. "They haven't been proven effective."
Martinez said the surcharge could discourage people from buying health insurance, which could leave some without the treatment needed to quit. Instead, the American Lung Association is in favor of states providing access to comprehensive treatment.
"Quitting tobacco is extremely difficult," he said. "And everyone is different. It's important that quitters have access to different treatments."
Insurers have added charges to smokers for some time, Gold said, adding that the Affordable Care Act specifies that insurers can underwrite premiums based on geography, tobacco use, family size and age.
"If they could underwrite other behavior related issues (such as obesity or drug use), they would probably do so," he said.
A slippery slope
Although insurers aren't able to charge higher premiums for other behavior-related health risks, a separate rule allows employers to charge obese employees 30 to 50 percent more of what the workers contribute toward their health insurance benefit if they don't participate in a wellness program.
A 2012 report estimates that obesity is adding $190 billion to health care costs each year, contributing to type-2 diabetes, heart disease and even some types of cancer.
The state also estimates that 30.4 percent of Iowans are obese, making the state's obesity rate the 12th highest in the country.
According to the CDC, an adult is considered obese if he or she has a Body Mass Index of 30 or higher, or more than 20 percent above his or her ideal weight.
Dr. Georges Benjamin, executive director of the American Public Health Association, which advocates for public health issues and policies, said charging extra for the behaviors is a slippery slope.
"We would prefer that this hadn't been done in a punitive manner," he said. "We'd rather insurers offer a discount for things that improve your health."
Benjamin said that addictions such as smoking and overeating are behavioral as well as chemical, which makes it hard to quit. He said it's important that the government and insurers offer comprehensive treatment, including access to weight-loss coaching, counseling and smoking cessation.
"It's not like when car insurers give discounts to people when they put a seat belt on," he said.
Americans support smoking charges
More Americans favor higher prices for smokers than obesity
An August Gallup Poll shows that 58 percent of Americans believe health insurance companies are justified in setting higher rates for people who smoke, but only 41 percent support higher rates for those who are significantly overweight.
This may reflect the prevalence of these issues in the United States, Gallup said, because while 45 percent of Americans in Gallup's July Consumption Habits survey said they were overweight, only 19 percent said they smoke.Results show that those who are overweight or smoke are less likely to support higher insurance premiums. Twenty-eight percent of Americans who have smoked in the past week believe that higher insurance rates for smokers are justified, compared with 65 percent of those who have not smoked.