Health Policy Brief
May 10, 2012
Workplace Wellness Programs
The Affordable Care Act of 2010 will, as of 2014, expand employers'
ability to reward employees who meet health status goals by
participating in wellness programs--and, in effect, to require employees
who don't meet these goals to pay more for their employer-sponsored
health coverage. Some consumer advocates argue that this ability to
differentiate in health coverage costs among employees is unfair and
will amount to employers' policing workers' health.
Wellness program content
Typical features of wellness programs are health-risk assessments and
screenings for high blood pressure and cholesterol; behavior
modification programs, such as tobacco cessation, weight management, and
exercise; health education, including classes or referrals to online
sites for health advice; and changes in the work environment or
provision of special benefits to encourage exercise and healthy food
choices, such as subsidized health club memberships.
Inducements to participate
Although almost all workplace wellness programs are voluntary, employers
are increasingly using incentives to encourage employee participation.
These incentives range from such items as t-shirts or baseball caps to
cash or gifts of significant value
Employers are also linking participation in wellness programs to
employees' costs for health coverage--for example, by reducing premium
contributions for workers who are in wellness programs, or by reducing
the amounts they must pay in deductibles and copayments when they obtain
health services. Another trend among employers who offer multiple health
plans is to allow participation in a comprehensive plan only to those
employees who agree to participate in the wellness program. Those
employees who do not participate in a wellness program are offered a
less comprehensive plan, or one that requires them to pay more in
premiums or cost sharing.
What are the concerns?
There is widespread support for wellness initiatives in the workplace
among both employers and employees. At the same time, there is conflict
over programs that tie rewards or penalties to individuals achieving
standards related to health status--and especially over those
arrangements that affect employee health insurance premiums or
In general, business groups want employers to have maximum flexibility
to design programs with rewards or penalties that will encourage
employees to not only participate but also to achieve and maintain
measurable health status goals, such as quitting tobacco use or reducing
body mass index. They argue that individuals should bear responsibility
for their health behavior and lifestyle choices and that it is unfair to
penalize an employer's entire workforce with the medical costs
associated with preventable health conditions as well as the costs of
Unions, consumer advocates, and voluntary organizations such as the
American Heart Association are generally wary of wellness initiatives
that provide rewards or penalties based on meeting health status goals.
They are concerned that, rather than improving health, such approaches
may simply shift heath care costs from the healthy to the sick,
undermining health insurance reforms that prohibit consideration of
health status factors in determining insurance premium rates.
They argue that such incentives are unfair because an individual's
health status is a result of a complex set of factors, not all of which
are completely under the individual's control. For example, genetic
predisposition plays a significant role in determining many health
status factors, including such attributes as excess weight, blood
pressure, blood sugar, and cholesterol levels. Consumer advocates also
caution that poorly designed and implemented wellness initiatives may
have unintended consequences, such as coercing an individual with a
health condition to participate in an activity without adequate medical
Another concern is that tying the cost of insurance to the ability to
meet certain health status goals could discriminate against low-income
individuals or racial and ethnic minorities. These individuals are more
likely to have the health conditions that wellness programs target and
also may face more difficult barriers to healthy living.
These barriers may include some that are work related, such as having
higher levels of job stress; job insecurity; and work scheduling issues,
including shift work. Barriers outside of work may include personal
issues, such as financial burdens, and environmental factors, such as
unsafe neighborhoods, poor public transportation, and lack of access to
In addition, some critics warn that wellness program requirements may be
used to discourage employees from participating in their employers'
health benefits plan by making their participation unaffordable.
Employers might use a system of rewards or penalties totaling thousands
of dollars annually to coerce employees who cannot meet health status
goals to seek coverage elsewhere, such as through a spouse's plan; a
public option, such as Medicaid; or a separate private plan purchased
through the new health insurance exchanges.
Comment: Altruistic employers who, out of the goodness of their hearts,
offer wellness programs to their employees, also theoretically benefit
by improving productivity through having a healthier work force. These
are admirable goals. But employers are now playing the blame game as
they use their programs to penalize employees who have medical needs, by
reducing their health care benefits and increasing financial barriers to
Employers can enhance employee health through work-sourced exercise and
nutrition programs, through work safety measures, and through programs
such as smoking cessation. In sharp contrast, disease screening should
be provided privately in an entirely separate primary care environment
where the screening is a part of a comprehensive, integrated health care
program that belongs to the patient, not the employer.
Above all, whereas the medical health status of employees should be
maintained through the health care delivery system, never, never should
the employer be allowed to reduce health care benefits because the
employee has greater needs.
This is yet one more reason why health insurance should be totally
dissociated from employment. If we had an improved Medicare that covered
everyone, health care access would be continuous throughout life, and
barriers to care could never be used to punish individuals unfortunate
enough to have manifested or contracted medical problems.