Dying for a Smoke? Cigarettes versus Mevacor; can't wait until you pay for it

Earlier this week, I had a patient in, visiting me for the first time. He basically a "syndrome X" type of guy: middle-aged, overweight, high cholesterol, high blood pressure. He's not the most personally careful individual, with a history of domestic altercation, some prison time. Almost goes without saying he drinks too much and smokes cigarettes.

Well, now, he wants his cholesterol medication restarted since he has just now started receiving "insurance", i.e. Masshealth, Massachusetts' state welfare benefits program. He tells me he couldn't afford cholesterol medication on his own, notwithstanding a "heart attack scare" a year ago -- and stopped it, after having had it prescribed a few years prior.

Couldn't afford cholesterol medication on his own? Well, a bit of simple calculation shows that he spends about five dollars per day on cigarettes, and at least that much per day on alcohol. If he had chosen to purchase generic Mevacor for his cholesterol -- a fine, cholesterol-lowering, statin medication for the most part, although not state-of-the-art -- he probably would have been out about $.50 per day.

Now that he has "insurance" (call me old-fashioned, but I see insurance as a policy that you actually have to spend on in advance as a gambling hedge against later infirmity while you're actually young and healthy; not a gifted grant of benefits unpaid-for), he is happy to have the other citizens of Massachusetts take care of his cholesterol issue, now five years worse than it would have been had he been able to take some of his cigarette- or alcohol-money -- really only 1/10th of it, and invest it in himself.

How do we get people to properly invest in themselves? Probably there has to be some downside to ignoring one's health problems, rather than having your problem just drop into the laps of your more conscientious fellow citizens. Can you help me with this conundrum?