Companies have long utilized "incentives" to encourage employees to participate in health-promoting programs - that is, they provide rewards to employees who meet certain health-related goals. As health care costs have begun to rise in the United States, however, such incentives have taken what some call a troubling turn.
Numerous companies have redefined their health care incentive programs, focusing on punishment instead of positive reinforcement. Moreover, many of these so-called "health" initiatives center around a single goal: losing weight.
CVS Caremark, which employs over 100,000 individuals in the United States, recently announced that employees who do not submit to body mass index (BMI), blood glucose, and cholesterol testing and report their results to the company's benefit firm will face a fine that amounts to $600 annually.
In a statement released by the company, CVS outlines the rationale behind its new program. It states in part: "our benefits program is evolving to help our colleagues engage more actively to improve their health and manage health-associated costs. An initial step to accomplish this goal is a health screening and wellness review so that colleagues know their key health metrics in order to take action to improve their overall health, if necessary."
Similarly, Honeywell International Inc. announced a $1,000 penalty for employees who opt to have certain forms of surgery without consulting a company program for alternative options. And employees of Michelin North America who have waistlines of a certain size or high cholesterol could also see their health coverage shoot up dramatically in the next year. Soon these programs will become a mainstay of American companies with employer-sponsored healthcare, as the Departments of Labor, Treasury and Health and Human Services just released an official ruling stating as of January 1, 2014, companies can charge workers up to 30 percent of their insurance premiums for failing to meet certain health goals. The administration bases its ruling on research supporting the efficacy of these plans, but also allows for an opt-out option; individuals, for example the elderly, who cannot meet certain health goals as confirmed by a physician, can pursue certain alternative programs.
Ruth Linden, a bioethicist and health policy expert, notes that a major problem with these programs is that they overwhelmingly suggest health and weight are interchangeable, which is simply not the case.
Further, "most popular weight-loss diets promote unhealthy eating and can be harmful to one's overall health," says Linden. "For some people, in some cases, it is much safer and healthier to keep a higher body mass."
According to public health professional Katherine Jones, "Weight alone should not be used as an indicator of health and focusing on weight loss as a goal in health interventions can have some unintended negative outcomes."
"While I recognize this relationship between our increasingly unhealthy environments/lifestyles and our increasing size," she adds, "I don't think that it's as clear-cut as many in our society make it out to be."
These companies are trying to simplify an equation by focusing on their bottom line under the guise of concern for employee health, which could have devastating repercussions for employees.
The Experts Weigh In
Psychologist Dennis Kravetz, who conducts research on the correlation between wellness and productivity, insurance costs and returns on investment for corporations, particularly those that champion healthy living, explains the transition our nation is witnessing.
"The [health insurance] premiums rise each year at a much greater rate than inflation and company executives want to control these costs so they can afford them and not ask employees to pay for all of the premium," says Kravetz.
"Companies are also aware that a small percentage of their workforce can account for the majority of health insurance costs," he adds. "It is common, for example, to see 5 percent of the employees account for perhaps 60 to 70 percent of the total cost of health insurance."
"Most of that 5 percent group is not in this situation because of an automobile accident which was not their fault, genetic defects, etcetera; rather it is poor lifestyle choices," he said.
Kravetz, who has considered both sides of the debate, believes a punitive policy should be a last resort, yet he notes that charging some people more based on lifestyle factors is not unprecedented in the insurance industry.
He offers an example: "Drivers who have accidents involving DUI or lots of tickets, if they can get insurance, pay a lot more than the typical driver does, and this has been going on for years."
Others vehemently oppose these penalizing policies based on principle. They argue that companies should not be allowed to dictate what employees do with their bodies or in their lives outside the workplace.
Linden says these "employee surveillance policies" represent "an escalation of the dismantling of workers' benefits and more backlash against the climate of health care reform."
"Health care is a right, and employer-sponsored health insurance is a form of compensation," says Linden. "There is no difference between my employer telling me how I am supposed to be accountable for my health metrics and telling me what food I should eat or about other aspects of my personal life."
Linden is disturbed by the prospect of employee surveillance. "There's a line between private life and my public behavior, and my employer does not have the right to encroach on my private life," she adds.
While Kravetz notes overall wellness leads to better productivity in the workplace, Linden says there are many behaviors that diminish one's workplace productivity but they are not part of the contract one signs with his or her employer.
She provides several pertinent examples: "I did not say I won't go to bars and drink; I will not stay up all night and do lines of cocaine; I will not engage in unsafe sex which puts me at risk for STIs; I will not stay up all night reading novels and be exhausted."
"We all take risks, and part of living in our society is balancing risks you take with consequences," explains Linden. "We all eat sugar or have the glass of wine when perhaps wisdom might suggest we not. It's part of being human. How far outside of the domain of work does the employer get to control what their employees do?"
Linden argues that if we want to intervene to make people healthier in our society, the workplace is simply not the proper arena, nor should we focus single-mindedly on size.
Who's Impacted: Defining "Healthy"
Some wellness program critics argue that an individual's health is far more complex than the numbers on a chart. For one, BMI, common criteria for defining appropriate body fat ratio, is contentious in the medical community as an indicator of health and varies widely in what it indicates about a person's wellness.
In 2009, mathematician Keith Devlin outlined for NPR ten reasons BMI is "bogus," including the notion that "there are distinct categories of underweight, ideal, overweight and obese, with sharp boundaries that hinge on a decimal place." BMI also assumes, for instance, that there is such a thing as the objective "common man."
Jones adds: "Someone can have a technically unhealthy BMI (over 25) but still be healthy, while someone who has a normal BMI can be unhealthy."
Meanwhile, Michelin's program would penalize men with waist sizes above 40 inches and women with waist sizes above 35 inches, a similarly arbitrary cutoff by many accounts and one which narrows the definition of health to a single number.
Jones notes that while BMI is not necessarily an apt indicator of health, even if someone has a high BMI and is considered to be unhealthy, he or she still deserves equal respect, which is notably lacking in our society.
Jones indicates a study conducted by the Journal of General Internal Medicine in 2009 which found that the higher a person's BMI, the less they are respected by their doctor, a troubling prospect if we are to suggest employees can be coerced by their employers into getting their numbers tested. These programs have the potential to not only introduce a workplace atmosphere which promotes fat-shaming mentalities, but to deter people who look a certain way from applying for these jobs in the first place for fear of this hostile environment.
"Discrimination against fat people is endemic in our society regardless of health or productivity," says Linden. "One cannot justify discrimination because he believes a person is 'unhealthy.'"
"We are being targeted with substances that make us fat and do these things to our body so food companies can make money," she adds. "Those who can't resist [or whose options are limited] we target; that's not how you incentivize."
Further, Joel Winston, a New York attorney with a background in labor and employment law and former deputy attorney general for the State of New Jersey, explains, "Obesity (defined as high BMI) is an entrenched problem that's not easy to fix or eliminate."
Urging employees to get their numbers tested at the risk of financial penalty thereby more closely resembles a bullying scare tactic and would likely produce less effective results than holistic wellness programs, which inform and encourage rather than shame.
"There's also the "Biggest Loser problem," continues Winston, "in that, for many 'severely obese' workers, losing 50-150 pounds would be a life-changing success, but not enough weight to achieve 'normal BMI.'"
Jones and Linden agree on another factor: these policies disproportionately impact poor people of color, who tend statistically to be impacted more by obesity due to issues of poor access, education and increased job-related stress.
Future Hiring Trends
Experts worry what the future holds as these policies snowball and the lines on what is acceptable employer policy continue to blur. While it's no stretch to think of subtle ways prospective employers might modify their desired employee profiles - consciously or not - Winston and Linden both speculate on a frightening future for health care and employee rights. For many, their predictions are likely beyond the scope of what has even been considered.
As Linden explains, "This is a trend, and companies will do it more and more, and in some period of time this will become normalized. That is very dangerous."
They also note the impacts the "surveillance" mentality could have on hiring and promotional practices, beginning with perks distributed in the workplace that could be affected by these metrics. Linden, pointing to a report revealing the US Army targets its disabled in cutting benefits, adds that health metrics could even play a role in a firm's decisions when it comes to downsizing its workforce,
According to Winston, "As this area of the law develops, it will be interesting to see how far companies push to acquire health assessment and 'future predictive' data on employees and their covered family members."
"Although BMI is a generally accepted method of medical analysis, it's hardly insightful from a cost reduction standpoint," he says. "With the availability of avalanches of medical, consumer and social media/lifestyle data, it's simply a matter of time before companies impose growing demands on employee disclosure or simply buy publicly available data files."
While we would like to believe - and generally assume - we are protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Linden and Winston agree these laws are not sacred.
"Unfortunately, health privacy laws such as HIPAA offer little protection because consumers will be required to provide individual consent to disclosure during the hiring process or the insurance application phase," notes Winston.
Linden adds that there are already often data breaches under the most egregious circumstances and there are not sufficient laws in place to ensure they do not occur.
"HIPAA is rather limited," she says. "It's as limited as the people who implement it - people who are not always smart, careful and conscientious. With record consolidation becoming more seamless, this is really quite scary."
"Will employers try to collect metrics or have access as they might try to go on your Facebook?" she posits. "I don't think it's extreme or paranoid or hysterical to wonder. It seems like the next logical step. There is an immense amount of information floating around out there."
Some might argue that when left to speculate about the future of hiring practices, it's easy to get carried away.
Linden says data mining is a booming business and "companies that collect data and analyze it and re-sell it and make inferences or look at correlations and health metric trends" present a danger to prospective employees.
"I think looking at proclivity for cancer is next," she says. "And it's not difficult to infer these from other metrics."
And even if specific data is not available? "If there is an absence of number data for individuals, there will be inferences made based on other markers that will serve as surrogates for specific numbers that refer to specific bodies," speculates Linden. "That's really easy to do."
Ultimately, whatever the future holds for hiring practices, Linden says these punitive programs simply will not work because their very premises are flawed.
Not only do wellness programs promote a demeaning and slippery surveillance mentality, their fundamental understanding of health is inaccurate.
"They are going to backfire badly,” says Linden. “They are not based on what we know works. They may be best for shareholders in the short run in maximizing profits, but they will not produce a healthier employee group."