12/08/2009 4:00 pm
POV
The Real Cost of a 'Botax,' by Plastic Surgeon Dr. Haideh Hirmand
A noted physician exposes the hidden toxicity of the Senate's proposed 5% federal tax on cosmetic procedures.
Editor’s Note: Dr. Haideh Hirmand is a noted plastic surgeon,
academic and thought leader in the aesthetic and beauty arenas. She
completed her Doctorate in Medicine at Harvard and is Clinical
Assistant Professor of surgery at the The New York
Hospital/Cornell-Weill Medical Center. She specializes in eyelid and
facial rejuvenation, secondary breast surgery, body contouring and is
recognized nationally as a pioneer in injection techniques. Click here to learn more about Dr. Haideh Hirmand.
Thinking about a touch of Botox before your next event? Perhaps a little filler before your next job interview? Or even some liposuction now that menopause has hit and no matter what you do, you’re carrying a little extra plumpness around the middle? You may want to move fast or consider a trip abroad or even start researching non-licensed practitioners who can perform these procedures. Sounds ridiculous, doesn’t it?
When I first heard about the 5% tax on elective procedures that is being proposed in the Senate health-reform bill, there was a moment of "wow" – and then I paused to reflect. The "wow" came because there was intuitively something arbitrary and bizarre about the tax, which came out of left field. Why the pause? I am not part of the knee-jerk opposition that immediately balks at anything from the right or the left. After all, as physicians we understand the need and value of health-care reform that actually improves access to and quality of care. I also understand the fiscal constraints of these times and the need to limit expanding the deficit.
So last week, one of my out-of-state patients sheepishly observed – with the kind of guilt that often accompanies cosmetic surgery – that the proposed "Bo-tax," the first federal tax of its kind, would probably not make a big difference for my patients. Inspired, I set out to do my own research. I knew that next door in New Jersey there was a similar state tax in place, so at least we had a small model to look at. The more I learned, the more outrage I felt. Here’s what I found out.
The tax discriminates against women: According to the American Society of Aesthetic Plastic Surgery (ASAPS), 91% of all cosmetic procedures are requested by women. In fact, a full 86% of plastic surgery patients are working women. And these procedures are not always done to look younger but many times to deal with side effects of multiple pregnancies and such.
The tax is a middle-class tax in disguise: Much to my own surprise, according to the American Society of Plastic Surgeons (ASPS) data, 71% of surgeries were for individuals making less than $60,000 a year. These are not people living on Fifth Avenue or in Beverly Hills. According to an ASPS survey, among those planning to have cosmetic procedures within the next two years, 60% reported annual income of $30,000 to $60,000. Only 10% of this group reported income higher than $90,000. The demographics of plastic surgery patients have obviously shifted dramatically over the decades and it is no longer just a "luxury" for the rich and famous. In my own patients, I have many who consider it a necessity to remaining competitive in the workplace.
The tax will seriously compromise patient safety and cause increases in unsafe medical tourism: What most don’t know is that the provision is limited to procedures performed by "a licensed medical professional." You can bet that the easiest tax loophole is to seek these procedures from non-medical personnel in all sorts of inappropriate locations. Already there are problems with complications and even death from cosmetic surgery and procedures performed in salons and by non-qualified personnel. This is such a disastrous consequence and such an obvious one that I would oppose it for that reason alone. Is there such a lack of thoughtfulness about patient safety and the forces that would undermine our efforts to keep patients safe? Additionally, the tax is sure to drive more Americans abroad for these procedures. News programs everywhere have reported on horror stories resulting from medical tourism.
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OK, I will play Devil’s Advocate a little bit, though I have to say there is a lot about this that I don’t like at all.
First - for ELECTIVE procedures, I don’t see discrimination in the tax. One need not have ELECTIVE surgery at all. One can as easily argue about discrimination related to other parts of the tax code: Child Care Credits discriminate against the childless; property taxes discriminate against property owners; cigarette taxes discriminate against smokers. I could put forth arguments against any of these things.
Second - on medical tourism: in the case of New Jersey, it was easy for patients to skip over the state border and find a doctor in another state. It is not so easy to skip over an international border, and the costs of travel and accomodation pre-op and post-op, plus any complications or follow-up, will almost certainly outweigh the cost of a 5% price increase on a US procedure.
But then you touch on the points that I find indefensible: NO, doctors should not be made into tax collectors; and NO, the IRS has no business deciding what was elective and what was not. We already have too many problems of that ilk between doctors and insurers. In fact, the IRS has no business poking around medical records at all. Have they never heard of HIPAA?
I also agree with you that this creates a slippery slope on what procedures could be taxed as "luxuries." A century ago, no one had knee or hip replacements, and two centuries ago, there was no general anesthesia… so… I guess those might be luxuries, too!
Thanks, Lila, for this response. It is just brilliant. As a childless by choice, single by choice woman, I have paid my tax-dues for BOTH those decisions year after year after year. But these were my personal choices, and my ability to choose freely is worth the taxes I have paid. And so I feel your argument about ELECTIVE procedures such as Botox, lipo, etc. is a very sound one. But as for getting the IRS involved in determining what is an "elective procedure", that is a nightmarish thought to me. After all, how many of us have shaken a fist (literally and/or metaphorically) at HMO "beancounters" who have complicated our current health system and our ability to make health decisions in consultation with our physicians to the point of insanity already? Now think about getting a bunch of federal bureaucratic CPA’s and tax lawyers in on it, and see where THAT ultimately leads. There will not be enough fists left to shake once we get the thin end of THAT wedge in place under the doors of medical offices. It not only makes no real fiscal sense, it invades all definitiions of doctor/patient confidentiality.
I think by that point, fists would not just be shaking any more!
Just a few years ago in Nepal, in a village which had never gotten one single benefit from the government… no roads, no electricity, no clinics or schools… nothing… the people built an ingenious little water-driven mill to grind their grain. Word of that eventually got out, and one day a tax collector came to tax the mill! The villagers tarred and feathered him. People can only be pushed so far.
I worry that things like this will push more doctors out of the medical business. My father’s cardiologist, who was very good, quit practicing and went into a salaried position in medical administration because he was burned out on all the requirements and expenses of running a practice, and had no desire to practice HMO medicine.
on the button lila!
BRAVO!
Well, something has to be done about the flagrant use of cosmetic surgery that is not needed. Granted, those who do need it, must be given the opportunity for the best care, and not be taxed; that’s a given. But, frankly, even your light-heared, almost joking manner about "a touch of Botox before your next event? Perhaps a little filler before your next job interview?" is not funny, nor professional in my opinion. Those are not necessary procedures. Every day in fact, we are distracted by the concrete faces of males (in particular) on TV who express themselves below the eyebrows.
Thus, it is not only women who are tripping off for their surgical readjustments, men are too. If the procedures are not a medical necessity, and I would give most board-certified plastic surgeons the right to make that determination, they should be taxed. Good heavens, all we hear in medicine and out of it, are how "back-up" our esteem collleagues are taking care of the sick. Well, let’s keep it that way and without taxation, but for those who opt in for the minute blades, and lasers, let them pay tax. Our health care system cannot afford any other option.
I am reminded something someone just sent to me; it might drive home the critical need to tax cosmetic procedures, also: "If congress fails to pass health care coverage this year it will not only be a political failure, but a moral failure as well. In the past 16 years since the last attempt for universal health care That is more Americans dead than those that died in WWI, WWII, Korea, Vietnam and Iraq combined!failed, there were nearly 700,000 unnecessary deaths."
Now, I went to Harvard, and came away with a far greater appreciation of science, and medicine, and the right for people to receive health care, and SPEAK UP if they don’t. Incidentally, the ASAPS is not the accrediting body of plastic surgeons. I think you should have made that clear. http://www.abfprs.org/
I agree Phyllis and yet to me anyway, the truth is that the Stupak amendment and the "Bo-Tax" is the same thing; Conservative men who continuely fixate on all things female and sexual as the either the cause or the cure for what ills our society. These guys just can’t get over the whole fable of "Eve sent Adam down the wrong road with that apple business so now we have to control, watch, dominate women as they can’t be trusted to use their own good judgement."
Apparently, either woman are causing society ills with our rampant mis-behavior…or…we are just to silly and emotional to be trusted with decisions that effect our bodies and our sexuality.
And always it’s the old moneyed white guys…the same ones that may very well ran our economy into the ditch we all now are sitting in.
Nice job boys…meh!