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.
Although I agree with many of your concerns, I am dismayed by what seems to be your overall sense that wellness programs are not likely to be a good thing. I think the authors of this blog are pretty consistently in favor of more healthy activity levels; I am, too, so here is what I did for my company: I began what I call a “wellness program,” but I pay for it with after tax dollars so it cannot be subject to any tax-related regulation; I got together with some others and talked over what it should cover, and came up with some pretty general guidelines – exercise, weight loss, smoking cessation, the usual. We talked about whether we would include running shoes or other equipment, whether we would ever consider outcome, and various other odds and ends. There is no outcome requirement; there is no tie of any kind to our medical insurance premiums. Once we had the plan, I handed the administration over to an employee who has no authority of any kind over people’s working conditions or compensation, but who has a history of handling issues requiring discretion. He hands me a note quarterly showing the total amount that was covered (one lump sum, no details of who used it, or what they used it for), and I reimburse the company with after tax dollars. If people have problems with him, they can come to me, but no one ever has. It makes me very happy to see the quarterly amount increasing slowly but steadily.
Getting active has changed my life in so many wonderful ways, I wanted to try to help others discover the benefits – and the joy. Although it may never be possible to measure the financial impact of this informal program, I know that it helps others, and that it improves their energy, their state of mind, and their enthusiasm for working here.
I just think we need to be cautious about casting a shadow over the whole concept of wellness programs associated with workplaces, since wellness activities can give so much to those who find ways to participate. By all means, point out the perils and the flaws in many of them, but let’s try not to put that under a universal wellness program label.
I don’t mean to have conveyed an overly negative impression of all wellness programs; thanks for your comment, which encouraged me to clarify that. Increasing your activity levels is generally beneficial and important, and it’s fantastic when employers support and facilitate this. Programs like the one you have for your employees are great!
While I raise a few concerns for wellness in general, what I find most troubling is a lot more narrow: specifically, outcome-based programs that involve large financial penalties to health insurance premiums, and especially those that focus on weight loss. I should have been clearer that most wellness programs are not like this — there’s no universal wellness program format, and while some wellness programs are problematic, many are not (and are downright wonderful!)
I also wonder why so negative vision of wellness programs, especially if they are activity-based? It’s wonderful that some employers are realizing that an employee who takes care of his/her health is happier, more energetic and more likely to perform better than a smoking couch potato. I don’t understand how someone loses with it? The people who don’t want to participate aren’t in any way punished. They just miss the benefits. And if you quit smoking the personal financial gains alone are huge, not even talking about the health benefits.
And as a person with a chronic illness, a job, lots of responsibilities and volunteering action who has before worked two jobs while studying full time: it’s bullshit to say you don’t have time to exercise. I’ve never ever met a person who couldn’t squeeze in 30 minutes EACH day if they only wanted to. Besides, healthy lifestyle and regular exercise gives you so much energy the tasks that before seemed overwhelming can turn into easy as pie.
>I’ve never ever met a person who couldn’t squeeze in 30 minutes EACH day if they only wanted to.
Well, apparently you have not met every person then. I don’t always have the ability to get 30 minutes of exercise in in a day, and I know many other people with disabilities with do not always have the spoons available for that as well.
Wanting to is not the issue. I want to be able to exercise everyday. I want to be able to come home from work everyday not so fatigued that I physically cannot do anything other than crawl in bed and get as much sleep as possible before I go to work the next day. I want to be able to fit in working full time, being in school, volunteering, eating well, and fitness into my life without feeling like it’s constantly a question of which one I can afford to drop off for awhile in order to not end up in a position where I can’t any of them going any longer. But unfortunately my body doesn’t really give a fuck about my wants, and wants don’t make my disabilities disappear.
I’m sorry to hear that. With my chronic illnesses I can totally relate to not having enough spoons for making it through the day, let alone everything I’d like to do. I didn’t in no way want to chastise people with disabilities but was referring to normal, healthy people with no physical limitations. I’m sorry for not being spesific enough.
I think this is a great post that brings up a lot of my own problems with employment wellness programs. Where I work, we’ve been doing a wellness program for a few years now. It feels coercive and invasive. Our insurance premiums are going up 11% this coming year, as well. I’m not seeing much win in it.
I have a lot of issues with these programs as well. I know you know this, but employers need to realize that lower weight doesn’t mean better health. Also, I agree that’s it’s overreaching of a company. We do fitness challenges at my work, but they’re not mandatory and there are prizes, not monetary incentives. If people don’t want to participate, they don’t have to. Also, gobs of research have proven that penalizing anyone (child, adult, or animal) with negative reinforcement doesn’t work and only ostracizes that person further. Lastly, you’re right about the inequities presented in the activity-based programs. Time can be a luxury that those who juggle many responsibilities don’t have.
I have attended but with no obvious benefits :). I think exercising is more about getting mentally ready.
Perhaps closer to the first commenter’s model (which sounds like a good one) my work has a basic on-site gym and employees may pay for membership with pre-tax dollars. But no one is rewarded for joining or coerced into working out. It’s just a benefit we may take advantage of, and it’s convenient. In addition, at their discretion, many supervisors allow their employees to take 30 minutes at the gym as part of their work day.
I wish “wellness” plans at work, and also public health initiatives for that matter, focused more on giving more options rather than financial benefits/punishments. My workplace has information on healthy eating to encourage that as well as an insurance plan with a higher cost for those who do not meet the standards for the healthy living assessment or choose not to participate. But what I would really love to see for encouraging healthy behaviors- how about an onsite gym that is free or reduced cost for employees? I would love that! Especially when we have an hour unpaid lunch break during the day and I don’t usually eat lunch. I’d much rather get in a short workout during that time, but if I have to leave and go to a gym/my home gym, that hour will be eaten up entirely or almost entirely in commute time plus changing clothes. Taking out the need to commute somewhere else would be a huge benefit (and also would be great for people to use before or after work hours as well, still not having to worry about an extra commute time.) Stuff like that is great to me, it gives people an ability to be healthier without punishing them if they can’t do it. If you physically can’t workout or you just don’t want to, the only benefit you don’t receive would be using the gym not having more take home pay.
I have similar feelings with workplaces that try to force things like walking. I’ve heard of some workplaces doing walking meetings to encourage more walking, which besides just sounding like an ineffective meeting method, becomes a barrier for employees with disabilities who might not be able to participate in a walking meeting. How about just making it easier and giving permission for employees to take a walk here and there if they want to? I’d love a workplace that specifically approved being able to get up from your desk and take a quick walk around the block to clear your head when you need to! (Which can also have positive effects on one’s thinking and productivity too.)
Yet for some reason it seems the focus is always less on “how do we remove barriers from employees who want to be more active/eat healthier/take better care of their health?” and more on “how do we make employees who don’t want to do these things do them?” (which also assumes that the reason people don’t is lack of wanting to rather than being unable to or wanting to but having work related barriers that make it difficult.)
Speaking of which also, if you want people to be healthier- how about more workplaces who make it easy to take time during normal business hours for doctor appointments? Many workplaces talk about health and then have leave policies that make it difficult for employees to get in to see doctors (who often are only working during those normal business hours as well!)
I’m personally a bit worried about when I have to go through the healthy assessment for my insurance, since my BMI is well over the “normal” limit and I’m not going to be getting down to the “normal” level. Interestingly for my insurance, it has no impact on premiums- the premium stays the same but your deductibles and copays go up. Which actually probably works out to be worse for me since I have chronic illnesses and thus more copays I have pay in a year than someone without chronic illnesses. Not to mention, speaking of barriers to health/healthcare- increased costs will be one! So basically then you are just trying to discourage people deemed less healthy from getting regular medical care by making it more expensive for them to do so?
All interesting from the perspective of a Canadian.
As long as the employer doesn’t make employee wellness “mandatory”, providing information and choice of different fitness classes on site can be a big help to people with very tight personal schedules. Having also on-site exercise rm. can help also. We don’t have “contests”. Instead there are employee profiles occasionally on our corporate internet about a person’s job and their personal lifestyle, habits. It’s good to profile a bunch of employees going for a lunch hr. walk or jog…or even a bike ride. It’s not to make others feel “bad” but subtle messaging that there are easy to do things with other employees if it works. We have over 10 different worksites across the city with some locations in semi-industrial, far-flung suburban areas.
I see employee wellness holistically….providing healthy transportation options..ie. secured bike rack storage. So think holistically and provide the on-site facilities to employees instead.
By the way, I work for govn’t. Our employee doesn’t give us any financial incentive to be healthier. What they are interested instead, is reduction in absenteeism.. and regular exercise can help some people in this …feeling abit less stressed, long term better health,etc.