by Alida Liberman
Do you like to attend exercise classes, or try to walk a certain number of steps per day? Would your answer be different if your employer gave you a financial incentive for doing so, or required you to pay a penalty if you didn’t? Have you ever attempted to lose weight, quit smoking, or lower your cholesterol? How would you feel if you had to pay 30% more for your health insurance if you didn’t succeed?
Many employers offer wellness programs for their employees. I’ll be discussing wellness programs as they are outlined in the Affordable Care Act (ACA) in the United States, although wellness programs exist in other countries, as well. Some wellness programs do things like provide employees with free gym memberships or reimburse them for the costs of a voluntary smoking-cessation program. Other wellness programs offer financial incentives for participation. Such incentives can be activity-only or outcome-based. Activity-only programs grant rewards for participation in certain activities, such as a diet program or exercise regimen. The results don’t matter; participation is all that counts. Outcome-based programs grant rewards to people who achieve specific health goals, such as lowering their cholesterol, BMI, or blood pressure. With these programs, results matter; you are rewarded if you succeed or penalized if you don’t, no matter how hard you try.
As of 2014, under the ACA employers are allowed to offer employees who participate in wellness programs up to a 30% discount on the premiums they pay for their employer-sponsored health insurance. (To read more about this policy, click here.) While this is often framed as a reward or bonus for those who participate, it can also be construed as a penalty for those who do not participate, as they have to pay up to 30% more than their participating peers.
This might seem at first glance like a win-win scenario: employees receive a benefit for participating in a program that makes them healthier as a result, which means that employers spend less on the healthcare costs that they are required by law to cover. But things are not as simple as they first appear. First, it’s not clear whether these programs actually save employers any money, especially when they focus on weight loss goals. And if any savings to employers are involved, it’s usually because costs are shifted to employees who do not participate in or meet the goals of wellness programs. More importantly, outcome-based wellness programs are morally troubling for multiple reasons, some of which I’ll discuss here.
First, outcome-based programs presume that the health goals they set are attainable—that with enough effort and determination, anyone should be able to reach them. But that’s not true, especially not for weight-related goals. Numerous studies have shown that dieting doesn’t work, and that we have a lot less control over our weight that most people think; even with exercise and a balanced diet, long-term weight is really hard, and for many people, impossible without surgery. And although the ACA requires that employers provide “reasonable alternative standards” for those who cannot meet the specific outcome-based goals they set, these standards might still be overly burdensome (e.g., an employee who cannot realistically get her BMI to a “normal” rate of 25 might be required to lose 10% of her body weight instead, which might still be very difficult goal to safely attain.)
Second, the particular health goals that are set by employers might be inappropriate. For example, employers might set an outcome-based goal that employees fall into a certain BMI range. But it’s widely recognized that BMI is a deeply flawed standard by which to judge whether an individual is at a healthy weight: it was developed to apply to whole populations rather than individuals, is based on flawed science, and doesn’t account for the difference in density between muscle and fat, which means that muscular folks with low body fat percentages are often inaccurately classified as obese. Financially penalizing employees for failing to meet a bogus standard is a big problem.
And penalizing employees for failing to meet particular weight goals would be problematic even if the goals were fixed by a better standard. For health and weight do not go neatly together in the way that many people assume: people who are “overweight” or “obese” according to the BMI can be very healthy, while people of “normal” weight can be very unhealthy. Furthermore, employees might be perversely incentivized to engage in disordered eating or other unhealthy behaviors in order to meet their target weight goals—in which case, the wellness program would have the opposite of its intended effect.
Third, if the financial incentives are large enough, we might worry that participation in the wellness program is not really voluntary, and that the employer is being coercive. It’s not clear at what point (if any) rewards can become coercive—if an offer can ever be so good that it cannot reasonably be refused. It’s even more likely that large penalties can be coercive. And workplace wellness programs might lead to peer pressure from co-workers to participate, which might be problematic.
Fourth, we should be concerned about inappropriate employer overreach. Are the health habits of employees who are off the clock really the business of employers? Attempting to alter these habits might seem unduly invasive, even if it does save the company money by reducing healthcare costs. It isn’t appropriate for a company to incentivize a certain behavior simply because it saves them money. For example, pregnancy and childbirth incur healthcare costs, but this doesn’t mean that employers can reward employees who do not get pregnant, or financially penalize those who do. Or consider how studies have shown that being in committed romantic relationships lowers stress levels, which leads to a reduced risk of disease. Does this make it okay for employers to reward employees who are already in such relationships, pay for couples counselling or eHarmony memberships for those who aren’t, and penalize those who fail to form such relationships? Clearly not; employers do not have the right to involve themselves in the private lives of their employees in these ways. Why then do they have the right to involve themselves in the private lives of their employees when it comes to weight loss and exercise habits?
Finally, I worry that wellness programs might disproportionately burden employees who are already unfairly burdened. For example, it’s harder for women to lose weight than it is for men, making it harder for women—especially women who have previously given birth—to attain outcome-based weight goals, which means that they are more likely to be financially penalized for failing to weigh a certain amount. Activity-only programs distribute burdens unfairly, as well. For participating in exercise regimens or diet plans requires a lot of time, as well as physical and emotional effort. Employees who work multiple jobs, who are attending school at night, who act as unpaid caretakers, or who have additional family and household obligations are the least likely to have such time and energy to spare, making them the most likely to be penalized for failing to participate. Finally, static financial penalties always disproportionately burden the least economically well off. Paying an extra $50 a month in health insurance costs might not be a huge burden for someone with a lot of accumulated wealth, but could be a massive burden for someone who has to stretch every paycheck.
For these reasons, I think we should be skeptical of many employer wellness programs. What do you think? Are these programs a good idea? What additional concerns do you have about them?
Alida Liberman is a postdoctoral fellow in philosophy at the University of Western Ontario. She received a Ph.D. in philosophy from the University of Southern California, and currently researches ethics and bioethics. In her free time, Alida enjoys cooking, craft beer, going to the theater, and reading about feminism on the internet.