By Jane Norman, CQ HealthBeat Associate Editor
June 11, 2010 -- How much personal responsibility do people bear for their own health? Should overweight employees and their families pay more in health insurance premiums than employees who regularly work out and sport a better body-mass index?
Those questions are at the core of a continuing unease among critics of George W. Bush-era workplace wellness regulations expanded in the new health care law. The law will allow employers to vary health insurance premiums based on how well employees do in meeting health standards.
But the workplace wellness provisions also represent a rare beachhead in the law for business groups who say employers want to control health costs and motivate workers to become healthy at the same time.
The next battle will come when the Obama administration writes more specific and complete rules defining the wellness provisions, a process that's just beginning.
Workplace wellness regulations first set in 2006 allow companies to apply penalties or rewards of up to 20 percent of the total cost of an employee's health coverage, based on whether the employee can achieve a specific goal — for example, a certain BMI, or body-mass index, a formula based on height and weight.
Under the new health care law, the figure can be as much as 30 percent of the cost of a company pays for health plans. The secretaries of Health and Human Services, Labor and Treasury are authorized to increase it to 50 percent. Those with "medical conditions" can opt out, but they have to provide verification of their condition.
Sue Nelson, vice president for federal advocacy at the American Heart Association, said her group was among dozens that strongly opposed this proposal, included in the Senate version of the health care bill. Nelson said the groups were assured that their concerns would be addressed when a House-Senate conference committee met to iron out differences in the overhaul measures. But the Senate bill was largely the version that became law.
It's not that the association opposes workplace wellness — the worry is that employers will establish standards without also setting up programs to help employees get healthy. "We have not seen evidence anywhere that simply charging people more for their health insurance, particularly for conditions like obesity, is going to really provide the incentive they need to lose the weight," Nelson said.
Sabrina Corlette, a research professor at the Georgetown Health Policy Institute, said such premium-tied incentives are particularly hard on working women with children who are most often the caregivers and pay less attention to their own health. "For low-income women who are heads of households, working two jobs, with no gym or safe place to walk — it's just much more challenging for them to meet" a health standard, Corlette said.
Bipartisan Support
However, senators on both sides of the aisle pushed incentives. Sen. Christopher J. Dodd, D-Conn., lauded as a "very sound proposal" what was suggested by three Republican senators and accepted by Democrats during markup. Sen. Tom Harkin, D-Iowa, chairman of the Health, Education, Labor and Pensions Committee, said incentives are used by companies with "great results."
Aides to Harkin said he resisted attempts to raise the reward or penalty to 50 percent immediately, thinking there isn't enough evidence yet to go that far. He will watch how the regulations are written, and wants to see protections against discrimination based on health status.
But when Starbucks spends more on health care than coffee beans, something is "seriously askew," said Harkin. "Corporations are spending untold tens of billions on illness, hospitalization, absenteeism and lost productivity," he said.
James Gelfand, director of health policy for the U.S. Chamber of Commerce, which supports the provision, said companies all across the nation host wellness programs. "Some work and some are completely ineffective," he said.
"What we've found is one of the best incentives is lowering employee premiums for health insurance," he said. "We've heard from companies that say that strategy is successful for them." Increasing the reward or penalty to 30 percent will help more of those programs succeed, he said.
Understanding motivation is not easy. A recent survey for the National Business Group on Health found that employees know how to get healthy but aren't necessarily taking action. Asked how well they do with getting exercise, just 22 percent said "great."
Interestingly, 75 percent of the 3,026 people surveyed said workers who practice healthy behaviors should pay less for their coverage. Robert Gould, president and CEO of the Partnership for Prevention, a nonprofit organization that brings together business and employees, said the main problem is there's not yet enough evidence-based research. It's understood that incentives are important, but some people may feel treated unfairly by the way in which they're used, he said.
"A carrot can become a frozen carrot that really is a stick," Gould said.