It made headlines in 2004 when New Jersey, in a misguided effort to raise state taxes, levied a 6% excise tax on Cosmetic Surgery. Now the nip-tuck tax is getting the axe.
Read My Lips … No Cosmetic Taxes
Today, New Jersey Governor Chris Christie signed legislation calling for the elimination of the state’s 6 percent tax on cosmetic surgery procedures. Medical procedures, like food, have always been tax free, but in 2004, New Jersey enacted the New Jersey Cosmetic Medical Procedures Gross Receipts Tax. A 6% gross receipts tax was required on all cosmetic surgery, hair transplants, cosmetic injections, cosmetic soft tissue fillers, dermabrasion and chemical peels, laser hair removal, laser skin resurfacing, laser treatment of leg veins, sclerotherapy, and cosmetic dentistry. All providers were required to register, report gross receipts and pay the tax quarterly.
This type of tax is called an excise tax. Excise taxes are taxes paid when purchases are made on a specific good. Excise taxes are often included in the price of the product, such as gasoline, alcohol and tobacco. There are also excise taxes on certain activities, such as taxes on wagering or taxes on highway usage by trucks.
Inefficient Taxation
Excise taxes are indirect, because the government does not collect the tax. Instead, and intermediary, like the producer or the merchant, is charged and they in turn pay the government. These types of taxes are inefficient and costly to regulate, and this is likely the reason the tax is being withdrawn. In the case of New Jersey, the annual tax collected was half of what was expected, about 10 million dollars. Furthermore, this was more than offset by an annual loss to the state of about 34 million dollars. This, among other facts, lead Joseph Cryan, the sponsor of the 2004 bill, to lead the repeal.
Who Decides What is Cosmetic Surgery?
There is not always a clear division between cosmetic and reconstructive surgery, and this makes this type of tax arbitrary and difficult to administer. The decision of medical necessity was left to those collecting the tax. This led to the taxation of cosmetic surgeries like those used to improve appearance after disfiguring accidents, port wine stain removal and even keloid scar removal.
A Tax on the Middle Class
With cosmetic procedures becoming more acceptable, it is no longer the exclusive realm of the rich and famous. Research by the American Society of Plastic Surgery found that 71 percent of plastic surgeries were for individuals earning less than $60,000 a year; moreover, only 10 percent of respondents reported household income over $90,000.
A Tax on Women
Research from the American Society for Dermatologic Surgery finds that 83 percent of its members’ minimally invasive cosmetic medical procedure patients are women. The percentage of women accounting for cosmetic surgery procedures approaches 90% in the yearly surgical statistics published by the American Society of Plastic Surgery.
Connecticut’s Cosmetic Taxes
Six months ago, Connecticut passed a 6.35% sales tax on all cosmetic medical procedures. Time will tell if the state suffers the same fate as New Jersey. It seems likely. With Connecticut being a small state, it is estimated that as many as half of Connecticut’s cosmetic patients will seek their care out of state to avoid the tax. This will have a significant negative impact on the state’s corporate tax revenue.
California’s Cosmetic Taxes
California considered a cosmetic tax a few years back, but with a greater appreciation of the complexities involved, the bill was withdrawn and exchanged for a 10% tax on tanning salons. This tax revenue should be reduced a little more this year thanks to a bill signed by Governor Jerry Brown that went into effect on Jan. 1, that bans indoor tanning for anyone under 18.
This month twenty-two Navy SEALs died in Afghanistan when their CH-47 Chinook helicopter was shot down. The group was attempting to help Army Rangers pinned down in a firefight. This is a deep loss to the military, but a far more tragic one to the families and friends of these mighty soldiers of SEAL Team 6.
This may seem off topic for the San Francisco Plastic Surgery Blog; however, I have had the honor and privilege of working with many hard working military men and women and their families. My office in the San Francisco Bay Area city of Walnut Creek, California is near Travis Air Force Base. Travis Air Force base is home to the 60th Air Mobility Wing, the largest wing in the Air Force’s Air Mobility Command. The base is named Brigadier General Robert F. Travis, who also died in and aircraft crash.
In this time of loss, I would ask you to consider joining our practice in making a donation to the Navy SEAL Foundation.
There are many ways to help the families of our fallen Navy SEALs, please consider:
Texting “SEAL” to 90999 to donate $10 to the Navy SEAL Foundation
Donate over the phone by calling 757-763-5501
Making an online gift under program area, there is a drop down bar, so you can direct your giving if you choose: To support the families of the fallen Navy SEALS – Afghanistan 8/5/11
The Navy SEAL Foundation gives 95% of donations to the families of SEALs killed in action. The funds cover memorial services (the military covers funerals only), travel expenses for the families of SEALs to attend funerals, child care expenses for widows, and other necessities for these families. The SEAL fund is a 501c3 non-profit, so your donation is tax deductible.
The average salary of a military service member is $38k per year. The families of these SEALs killed in action need our help. The Naval SEAL foundation estimates that nearly $1M is needed to help these families with memorial services and other necessities to adjust to life without their hero. Please consider making a donation today.
The American College of Obstetricians and Gynecologists is Looking Out For You
Doctors are once again at odds with the government, but this time it has less to do with Obamacare, and everything to do with saving lives, possibly yours.
Mammograms Save Lives
We all know that Mammograms save lives. National Cancer Institute data show the US breast cancer death rate, previously unchanged for 50 years, has dropped 37 percent since mammograms became widespread in 1990. The US Preventive Services Task Force (USPST); however, doesn’t seem to get it.
Early Detection is Key
While a mammogram doesn’t treat breast cancer, it is the key to the early detection of breast cancer. Another key is routine monthly self-examinations. The combination is an effective way to detect breast cancer in its early stage. The earlier breast cancer is detected, the better the chance that treatment will lead to a cure.
Cure rates are greater than 90% for breast cancers detected early. Earlier detection means smaller tumors. Smaller breast cancers spread less often and are removed more easily. On the other hand, if breast cancer is discovery after it has left the breast, treatments rapidly become more complex and are dramatically less effective.
Doctors Fight Back For Their Patients
The American College of Obstetricians and Gynecologists (ACOG) recently issued new guidelines, joining a long list of physician lead professional societies strengthening the stand that early mammography saves lives. The new ACOG recommendations call for mammograms more frequently than the previous ACOG guidelines. The previous guidelines recommended mammography every one to two years beginning at age 40, and then annual mammograms after age 50. The new guidelines recommend:
Mammography yearly beginning at age 40
Monthly self-exams for women at high risk for breast cancer
US Preventive Services Task Force (USPST) Recommendations Deemed Unacceptable
When the USPST recommended against routine mammography for women younger than 50-years-old, it was in direct opposition to the current standard of care. The Major Medical Organizations in the US where at first shocked and then adamantly vocal in their opposition. The recommendation would mean less money spent on mammograms upfront; however, the “savings” would be lost later in trying to treat larger tumors that are more likely to have spread. The ultimate cost; however, would be measured in lives not saved.
Thank you ACOG
Thank you to the American College of Obstetricians and Gynecologists for joining the long list of professional medical organizations, including the American Society or Plastic Surgeons, who disagree with the government’s suggestion to wait until age 50.
USPST WT?
When the American College of Radiology and Society of Breast Imaging made it’s recommendation that mammography should start at age 40, they used the USPST’s own data against them. After careful review, the USPST’s data did not support the recommendation of delaying mammography until age 50. I applaud the efforts made by organized medicine to bring this information to light. How this remains outside the main stream media is puzzling. With major health care “reforms” underway, this is an excellent topic for an investigative report, and early mammography will certainly save more lives than knowing where Casey Anthony is hiding.
You Are Worth It
Mammography, while not pleasant, is an effective screening tool. With 80% of breast cancer occurring in women without a family history, it is important for every woman to have access to the exam. If the government recommends delaying mammography a decade, the next step will be to stop paying for it. If government programs stop paying for the service, all insurance companies will follow.
Mammography allows us to detect and control the spread of breast cancer. If we allow a guideline delaying mammography to become law, it will be much more difficult for your doctor to order this simple, lifesaving test. If the USPST gets its way, unless you are willing (and able) to pay for your own yearly mammograms, you won’t be getting them. Your government may not think it is worth the documented reduction in breast cancer deaths, but your doctors do.
Please support your doctors in their efforts. We strive to practice effective medicine and protect our patients. The Hippocratic Oath mandates that we doctors do no harm. The USPST mandate delaying mammography until after age 50 would do harm, and allowing the recommendation to go forward unchallenged, would be just as harmful.
Lafayette Hillside Memorial Crosses (Click for High Res Image)
Thank You Veterans
Tomorrow is Memorial Day. While it is the unofficial first weekend of summer, it is also our chance to celebrate those who have died in the service of our country. Memorial Day was originally celebrated as Decoration Day on April 25, 1866, in Columbus, Mississippi, to honor Confederate soldiers killed at the Battle of Shiloh. In 1868, Decoration Day was observed at Arlington Cemetery with flowers and small American flags placed on the graves of Union and Confederate soldiers. Since then, the honor has been extended to all those who died defending the United States, and Freedom, during World Wars I & II, The Korean Conflict, Vietnam, Iraq, Afghanistan and throughout the world.
Lafayette Hillside Memorial
The picture above is a section of the Lafayette Hillside Memorial. The memorial was established in 2006 for soldiers who gave their lives in the Iraq War. A vigil we be held in their honor tomorrow night at 7 PM.
Memorial Day Observances
If you are looking for someplace to observe Memorial Day and give your thanks, here is a listing of some of the activities that are happening in our area:
Antioch – VFW program, Oak View Memorial Park, 2500 E. 18th St., Antioch, 11:00 AM
Brentwood – VFW local 10789 program, Brentwood Union Cemetery District, 11545 Brentwood Blvd., Brentwood, 10:00 AM
Clayton – Annual Memorial Day Program by VFW Post 1525, Downtown Clayton Flagpole, Main and Oak Street, Clayton, 10:00 AM
Martinez – All Veterans Memorial – Corner of Alhambra Ave and Berrellesa St, Martinez, 10:00 AM
Pinole – VFW, Fernandez Park, 595 Tennent Ave. Pinole, 10:00 AM
Pittsburg – Pittsburg Veterans Memorial, Harbor Street, Pittsburg, 10:00 AM
Walnut Creek — Gazebo at Walnut Creek Civic Center, Corner of Civic Drive and North Broadway, Walnut Creek, 10:00 AM
Danville – Vietnam Veterans of Diablo Valley , Memorial Day Ceremony, Oak Hill Park, 3005 Stone Valley Road, Danville, 10:30 AM
Pleasant Hill – Contra Costa Veterans Monument, Corner of Boyd and Contra Costa, Pleasant Hill, 1:00 PM
Lafayette – Lafayette Crosses (pictured above), Corner of Deer Hill and Oak Hill Road, Lafayette, Across from Lafayette BART station, Vigil at 7:00 PM
The 2010 Plastic Surgery Statistics are out. The American Society of Plastic Surgeons released statistics on America’s consumption of what plastic surgeons had to offer. Here is the recap for 2010:
Americans spent 10.1 billion on 18.4 million plastic surgery procedures last year. Here is how it breaks down:
13.1 million cosmetic procedures were performed, up 5% from 2009. This includes:
1.6 million cosmetic surgical procedures (up 2%) and
11.6 million minimally-invasive procedures (up 5%).
5.3 million reconstructive plastic procedures were performed (up 2%).
While teen plastic surgery continues to make headlines, people aged 13-19 had the least plastic procedures (cosmetic and reconstructive) last year, accounting for 2% of the total. The largest age group continues to be 40 to 54 year-olds, who make up 48% of all plastic surgery procedures.
If you, or your loved ones, are considering plastic surgery, be certain to consult with a Board Certified Plastic Surgeon. All members of the American Society of Plastic Surgeons and the American Society for Aesthetic Plastic Surgery are required to be Board Certified. Certification can be easily checked on the American Board of Plastic Surgery web site. Check your Plastic Surgeon’s Certification here. Apologies for how bland the American Board of Plastic Surgery site is. I’ve been trying to get them to rejuvenate the site for years.
The world is crazy. There has been a lot of chatter about terrorists implanting women with exploding breast implants in a effort to crash planes. But first, if you are reading this to find out if your normal, non-explosive, breast implants will explode the next time you board an airliner, rest assured, they won’t.
Why Your Breast Implants Won’t Explode in the Airliner
Airliners are pressurized, and must be maintained to atmospheric pressures below 8000 ft. While the air inside our ears and belly expands, the fluid inside breast implants barely does. Cabin pressure regulations are more complex than you might think. (Reasons for maintaining cabin pressure and the allowed tolerances can be found on Wikipedia’s Cabin Pressurization page.)
While Lady Gaga is red hot, and her fans may enjoy the visual, there is nothing entertaining about the sudden loss of cabin pressure. That would be a terrorizing event. TSA would not allow her to board with the outfit pictured to the left, the concern is that explosives inside a breast implant would be difficult to detect.
If you are still worried about your non-explosive breast implants, in the event of a complete loss of pressurization, your breast implants would easily survive the pressure change. Since they are mostly water, the breast implants would expand about the same amount as the rest of body. (I will not elaborate on all the real problems that would occur elsewhere in the body, but Wikipedia has a page on uncontrolled decompression with many unpleasant facts.)
Booby Traps
It sounds like a script contrived for a Hollywood movie: terrorist implanting their breast with PETN filled breast implants. The idea of surgically implanting an explosive inside the body is horrifying. Though from the terrorist’s perspective, it is only a short leap past strapping on a bomb. The worst part is, it is entirely possible. A small amount of explosive would be enough to disrupt cabin integrity, and cause explosive decompression with devastating results.
Media Coverage – KABC Los Angeles
It’s not surprising that the possibility was broadcast this February in Los Angeles.
But by March it has made world headlines on Fox News and The Sun. and the story is now being given further credibility by the need to discredit the report on True/Slant with science and with satire.
It Could Happen
Possible?
Yes. With enough determination and thought, anything is possible.
Probable?
No. I’m no terrorist, but there must be easier ways.
Reality
There is a fine fine line between a cautious and phobic. The reality is, we could spend our entire lives worrying about what could go wrong, and become paralyzed.
Bombshells not Bombs
As a plastic surgeon, the surgery I perform is elective and is held to a higher standard. While I worry about the complications of surgery, this is my motivation to achieve safer and more predictable results, day after day. This is why I spent years in training to become a Board Certified Plastic Surgeon. This is why I operate only in Accredited Surgery Centers, and use only Board Certified Anesthesiologists. This is why my patients trust me, and can keep their thoughts on the goal, rather than the process. No matter how bizarre the news from the outside world, when I am performing surgery, there is only one thing I am thinking about — my patients well being and happiness, and there is no greater gift I can give this crazy world than a happy patient. ( …and non-explosive breast implants)
As health care reform is being rushed to a vote before Christmas, it is hard for anyone to say what the bill includes. However, as of this morning, it does not include a tax on cosmetic surgery. I want to personally thank those of you who read my previous post, and made the time to contact your representatives. While there is no organized Cosmetic Surgery Lobby, your voice was heard, and it has made a difference.
Corporations like Allergan (from whom I purchase Natrelle Breast Implants, Botox Cosmetic and Juvederm) also went on record to oppose this unfair tax. More can be read here in MarketWatch.
While these large organizations helped to get the word out, what made the difference ultimately was you. You got involved. You called you Senators and Representatives, and for that I say, “Thank You.” The nature of the excise tax on Cosmetic Surgery was revealed and rejected, but there are more than 2000 other pages included in the Senate version of the healthcare reform bill.
While the bill is nobly entitled, “The Patient Protection and Affordable Care Act,” it has of late become “The Anything That Will Get Us 60 Votes Act”. The push to a vote before Christmas has lead to radical daily changes, and confusion about what “Patient Protection and Affordability” means.
I am interested in the outcome for many reasons. I am a Physician and my livelihood is directly effected by whatever is included in the yet to be finalized version of this bill. I am a health care provider, and I want to be able to take care of my patients in the ways that my training has determined are the best. I want the freedom to use my experience to choose the path with highest chance of success and lowest risk of injury. Unfortunately, rules and policies can only deal with large groups, and the decisions I need to make daily are on the level of the individual. Sometimes the needs of the one are different than the needs of the masses, and trying to get approval for a necessary test or surgery can be daunting when it is not the “normal” treatment.
I am interested in the outcome because I am in Private Practice. I not only provide medical care, but I purchase health care insurance for myself and my family. Medical coverage that as an individual, I cannot negotiate. Medical coverage that is provided in a take it or leave it fashion.
I am also interested in the outcome of The Patient Protection and Affordable Care Act, because I am a parent. Good health is one of the most important attributes we can have in a quality life. After good genes, quality healthcare is the key to good health. It is important that health care is made available. Public policy/support is a big piece of the solution, but equally important is the ability for your doctor to make a decision based on your situation. I cannot make my decisions based on what is right for the majority, I have to make them based on what is right for you, the individual. The individual is being lost in policy. Be it an insurance policy or a public policy the tyranny of the majority has found its way into medicine, and the policy being formed today will outlive all of us.
Many good ideas are left to be explored, and some aspect currently included need revision or unintended consequences may result. The selective excise tax on cosmetic surgery was not a good idea, and (for now) has been eliminated. Please continue to be involved, and contribute. The locomotive of reform has a full head of steam, and we need to keep it on track. Its shape changes every day, and the “true plan” has not yet been revealed. It is our healthcare that is being reformed, and it needs our attention.
Every time I hear another redundant news article on Tiger Woods, I wish instead I was being informed about something that actually will effect my life. The healthcare reform bill will effect my life. It will effect how healthcare is delivered in the United States, and will effect all our lives … directly.
The Healthcare plan in the Senate today will unfairly discriminate against you.
Raising the price of medical care.
I’m writing you today about an issue that affects not only plastic surgeons but everyone who utilizes our services for anything from Botox to Tummy Tucks.
No doubt, you’ve heard of the current healthcare bill before the US Senate? Page 2045 Sec. 9017, Excise Tax on Elective Cosmetic Medical Procedures included in the “Patient Protection and Affordable Care Act”. This dense legalese translates to a tax on all cosmetic procedures as partial payment for the healthcare overhaul our current administration is attempting to implement.
So what’s the problem? YOU would be paying this tax, the FIRST time this country has levied a tax on patients for medical procedures. What’s at stake?
• This will not have considerable consequences on the wealthiest patients but, as usual, affects the middle class. Working women, soccer moms, and scores of others who carefully save and budget to improve their appearance and self esteem will be penalized for doing so. 90% of all cosmetic plastic surgery patients have an income of less than $90,000.
• Procedures such as breast reduction that have been cited in the literature for improving self esteem and quality of life would be taxed as well. The procedure relieves chronic pain and changes lives for the better. This is the best of what medicine has to offer.
• Procedures not performed by plastic surgeons, such as Lasik surgery to improve vision, would also be taxed. It is likely that all procedures where payment is denied would be subject to taxation.
• Your doctor as tax collector: This provision places physicians in the role of tax collector and holds physicians liable should an individual fail or refuse to pay the tax. Is that the relationship you want with your medical provider? It is not the relationship I want with my patients.
The bill is large, and every sentence effects your medical care.
I urge you to personally inform the government that you are against this tax – together we can fight for your right to no government interference in medical care and stop this discriminatory measure against women!
You may recall that over the summer President Obama claimed he opposed any new taxes on households making less than $250,000 a year. According to the July 2009 issue of Gaurdian, while publicly making this claim, President Obama’s aides, and top Democrats were pushing for a cosmetic tax. According to Politico Treasury Department economic adviser Gene Sperling made the proposal. This cosmetic plastic surgery tax would be a tax on primarily women who earn less than $90,000 a year. A very small percentage earn more than $250,000 a year.
I can understand sin taxes on alcohol and tobacco which increase the cost of healthcare if those dollars are used for healthcare. It’s like forcing people to save for a known future expense (if they live that long). I cannot understand a tax on what the government decides is unnecessary surgery. Especially when the procedures relieve pain, improve vision, and otherwise decrease the need for further intervention.
My staff and I fight daily for patients’ rights to medical care. I debate with insurance companies about what is cosmetic and what is reconstructive surgery. There is no obvious line. Insurance companies are rewarded monetarily by denying claims.
If you are a proponent of the “public option”, you might be surprised to know that private insurance companies deny a smaller percentage of claims than government programs. Medicare currently denies more the six percent of claims. If they deny a claim, they don’t pay it. This saves them money. If they will get another 5%, or as originally proposed 10%, reward for denying claims, more procedures will be deemed unnecessary, and you, the patient, will be responsible not only for the cost of the procedure, but also for the tax on it.
The best thing about plastic surgery, both reconstructive and cosmetic plastic surgery, is that it helps people. It improves function, relieves suffering and makes people happier. And making people happy, makes those around them happier, and improves our society at its base. I would much rather spend my time doing that than talking about the above, but both are important.
Next week I will stop the politics, and get back to what I do best – Cosmetic Plastic Surgery in San Francisco’s East Bay Area community of Walnut Creek. In the mean time, get the word out. Inform your friends and tell your Senators how you feel.
EDIT: Allergan has organized on online petition here. This is another good way to get your voice heard; however, the most important way is to contact your Senators and Representatives directly. The feedback I am getting is that not enough people are speaking up, and this law is scheduled to take effect January 1, 2010, only a few weeks from now.
