(Previously: How Fat People Will Be Helped By The Affordable Care Act.)
There are of course a zillion things in the Affordable Care Act (ACA)1 which will apply to all Americans, including fat people; but in this post I’m concentrating on aspects that will disproportionately effect fat people.
The biggest potential harm to fat people under the ACA lies in “Wellness” programs. (This was brought up by Maia in a comment on her thread.) This provision was written into the Senate version of the bill (which then became the final bill) principally by Sen. John Ensign (R-Nev.). It’s supported by groups like the Chamber of Commerce, and opposed by unions and the AARP.
Under current law employers are allowed to create “wellness programs,” in which they give employees “incentives” for healthy behavior with discounts on their health insurance costs (or with lower deductibles or the like). Of course, there’s little practical difference between rewarding healthy employees, and penalizing allegedly less healthy employees. Current law says that “wellness plan” incentives/penalties cannot be more than 20% of the cost of the insurance plan.
However, beginning in 2014, the Affordable Care Act raises that maximum to 30% of the cost of the insurance plan. So if the value of your employer-provided insurance is $4,824, then under current law employers can penalize fat employees by up to $965; but once the ACA goes into effect in 2014, the maximum goes up to $1,447.
Here’s the really frightening part of the law: “The Secretaries of Labor, Health and Human Services, and the Treasury may increase the reward available under this subparagraph to up to 50 percent of the cost of coverage if the Secretaries determine that such an increase is appropriate.”2 Here’s a table from allhealth.org (pdf), showing how much extra people might have to pay per year under current law (20%), under the ACA beginning in 2014 (30%), and if the maximum is raised to 50%.
So is it going to be just a straight 30% extra charge for fat people who get their insurance through their employer? Most of the time, no, it won’t be. Since most employers with Wellness Programs don’t seem to be going all the way to the current 20% cap, it seems likely that they won’t go all the way to the 30% cap, either.
More importantly, under the law, employers are required to provide a reasonable alternative. Here is an example, from the Department of Labor, of how “Wellness Programs” are supposed to operate:
Example 4. (i) Facts. A group health plan will waive the $250 annual deductible (which is less than 20 percent of the annual cost of employee-only coverage under the plan) for the following year for participants who have a body mass index between 19 and 26, determined shortly before the beginning of the year.
However, any participant for whom it is unreasonably difficult due to a medical condition to attain this standard (and any participant for whom it is medically inadvisable to attempt to achieve this standard) during the plan year is given the same discount if the participant walks for 20 minutes three days a week. Any participant for whom it is unreasonably difficult due to a medical condition to attain either standard (and any participant for whom it is medically inadvisable to attempt to achieve either standard) during the year is given the same discount if the individual satisfies an alternative standard that is reasonable in the burden it imposes and is reasonable taking into consideration the individual’s medical situation.
All plan materials describing the terms of the wellness program include the following statement: “If it is unreasonably difficult due to a medical condition for you to achieve a body mass index between 19 and 26 (or if it is medically inadvisable for you to attempt to achieve this body mass index) this year, your deductible will be waived if you walk for 20 minutes three days a week. If you cannot follow the walking program, call us at the number above and we will work with you to develop another way to have your deductible waived.”
Due to a medical condition, Individual E is unable to achieve a BMI of between 19 and 26 and is also unable to follow the walking program. E proposes a program based on the recommendations of E’s physician. The plan agrees to make the discount available to E if E follows the physician’s recommendations.
The Washington Post has an article describing how already-existing corporate Wellness Programs have been run. The article indicates that some employers are using Wellness Programs as a means of shifting costs onto fat people (as well as smokers and people with high cholesterol).
Valeo, an auto parts supplier, four years ago raised the deductible on an employee health plan to $2,200 from $200 for individual coverage and to $4,400 from $400 for family coverage. Then it gave employees the opportunity to reduce the deductible to its starting point by not smoking and by meeting goals for blood pressure, cholesterol and body mass index, said Robert Wade, Valeo’s director of human resources for North America.
“If they don’t comply, they end up being penalized, if you will, but we refer to it as a Healthy Rewards program,” Wade said.
Workers who choose not to submit to yearly medical assessments have been offered a different health plan that carries higher premiums, Wade said.
The New England Journal of Medicine points out that at least one major “wellness” firm is marketing wellness programs as a way that companies can save money by encouraging employees to drop employer-provided insurance:
Direct and indirect increases would disproportionately hurt lower-paid workers, who are generally less healthy than their higher-paid counterparts and thus in greater need of health care, less likely to meet the targets, and least likely to be able to afford higher costs. Some employees might decide to opt out of employer-based health insurance — and indeed, one wellness consulting firm, Benicomp, implies in its prospectus that such a result might be desirable, pointing out that employees who do not comply might be “motivated to consider other coverage options” and highlighting the savings that would result for employers.
There are limits on what employers can do. Under new provisions of the ACA, employers whose employee’s premiums cost more than 9.5% of their household income will be penalized. And those employees are eligible for federal subsidies, or to join the Health Exchanges. However, as the Valeo case shows, fat employees who cannot meet “wellness” requirements could potentially be penalized with unaffordable copayments and deductibles.3
Valeo’s program was created when the maximum size of penalties was 20% of the cost of health insurance. By raising that maximum to 30% — or possibly to 50% — the Affordable Care Act will greatly increase the incentive for more employers to institute Valeo-style Wellness Programs. Looking at the track record of Wellness Programs so far, it does seem like many employers who use Wellness Programs aren’t using them abusively. But some are, and under the ACA it seems plausible that the number of employers using abusive Wellness Programs abusively will increase.
So the big question is, what happens to people who are priced out of their employer health care by “Wellness Programs”? Can they get on to the Health Exchanges instead? Or are they just screwed? I don’t know. I’ve been emailing everyone I can think of, trying to get an answer to that question, but so the only response has been from Senator Jeff Merkley’s office, which wrote:
All employees will be eligible to get tax breaks on a sliding scale (up to 400% of the federal poverty level or approximately $88,000 for a family of four) to help them afford coverage. This assistance is particularly beneficial for those on the lower end of the income scale.
If the insurance provided by an employer would cost workers more than 9.5 percent of their household income, that insurance is considered unaffordable and workers have a new option: purchase affordable coverage on the new health insurance exchanges, and receive a tax credit to make it easier to get the coverage they need.
In regards to your concerns about employees who want to participate in wellness programs but are faced with health issues, employers must offer “alternative standards” for individuals who find it difficult or inadvisable to meet those wellness standards. The goal is to ensure that there are safeguards to prevent discrimination and accommodate special needs. I can’t give you specifics on these standards because they have not yet been defined and HHS will be determining these standards and possible exemptions in the future.
So are the wellness provisions bad for fat people? I’ll go out on a cowardly limb and say we’ll have to wait and see.
Finally, I should note that even being on the Health Exchanges won’t necessarily mean an escape from Wellness Programs. The ACA also contains a pilot program, in which up to ten states may experiment with adding Wellness Programs to the Health Exchanges. I’m less worried about government-run wellness programs being abused — governments lack the profit motive, and so have less incentive to be abusive — but this still bears watching.
- Also known as “Health Care Reform.”↩
- You can read the relevant part of the Affordable Care Act by going here and then searching for the text string “(j) Programs”.↩
- There are possibly some limits on this within the ACA; insurance plans must have at least a minimum actuarial value to qualify, or else employers could be subject to penalties. What exactly that means — and how this interacts with the ACA’s provisions allowing for wellness programs — is beyond my ability to figure out.↩
Related posts:
It seems to me that anyone can tell the wellness programs to go jump in a lake, pay the penalty, but still have a lower insurance bill (or be able to get insurance at all) than under the old system. So the only “harm” is that someone else is paying less – and under every system except “everyone pays exactly the same for health care” there will always be some people paying more than others. And in this case the others aren’t paying less because of anti-fat animus – the bill is trying to change behavior, and there are ways to get exempted from the penalty.
I know there’s a trend where some employers reimburse you some of the money you pay to a gym as part of their wellness programs, if you can provide proof that you’ve gone to the gym X amount of times over X amount of time. That strikes me as a more fair way to encourage healthy behavior. But I can’t think of any other way to encourage healthy behavior that lowers costs without getting into unjust, repulsive monitoring of people’s bodies. Behavioral economics are a big thing now; I wonder if they’ve got any ideas.
Anyway, what do you think about programs that incentivize behavior, instead of penalize bodies?
I don’t mind them, personally, except I’m not sure how they get enforced. Spouse and I keep logs of our biking activity–how long before we’re called liars because I’m still fat? Will you need to exercise in front of people or something?
But I worry about the interaction of disability with the programs. People with depression or anxiety issues that they don’t want to share with their employers… these can be paralyzing and make physical activity unattainable. And that’s just one notion–I had a friend back in college who had a weird brain swelling that made her vomit constantly and have incredible pain. It took years for her to be diagnosed, and while the medical industry was still confused, she was ruled to be faking by the people who manage disability and unemployment. Before the diagnosis and eventual surgery to fix the problem (a happy outcome), it was a large financial burden. This would, presumably, be less of one–but knowing about experiences like that makes me wary of programs that increase the already strong American connection between health and morality.
There’s also something about privacy here that makes me twitchy. But then again, unprovoked drug testing by employers seems sketchy to me on the same grounds.
“the bill is trying to change behavior, and there are ways to get exempted from the penalty.”
It remains to be seen how well-implemented that will be.
Well, the employers I’m thinking of basically just record gym visits, which isn’t very privacy-invading. You have your gym print out a list of your visits, and you give it to them. I guess they won’t know if you go in, fart around in the steam room, and go home. But it’s reasonable to assume most people won’t make the effort unless they work out.
I agree that privacy concerns are a major issue, for sure. The key to a public health initiative is to create situations where everyone involved gets a cookie, i.e. is in a place to make rational, self-serving decisions that tailor to the goals. So, you sell needle exchanges to junkies by making them safe from prosecution (junkies are already motivated not to get HIV), and you sell them to the public by saying that it saves money.
The main motivation with these wellness programs is, at the end of the day, saving money. Some of the biggest financial drains when it comes to health insurance are diseases that are related to the poor diet and sedentary lifestyles of Americans—heart disease and type 2 diabetes, as well as some common forms of cancer like colon cancer and breast cancer. The aim then should be to create programs that address the financial concerns of employers but also tailor to the interests of employees.
Personally, I think employers could start by cleaning house. Not of employees, but of environmental incentives that they create that encourage bad diet and exercise habits. Sitting at a desk all day, having no time to eat a proper lunch? These things, more than anything, are the source of Americans’ downhill slide in personal habits. While a lot of people are averse to taking up intense exercise programs, most of us are happier if we get to move our bodies around more than the current office lifestyle allows.
Other things that spring to mind: Creating convenient lunch counters that only sell healthy salads, sandwiches, and fruit for lunch. Enrolling your office in a CSA and making it cheap and easy for your employees to get involved by discounting the veggies for them and having work delivery.
What stands out to me is that, once again, BMI is considered to be a good tool to measure “health”. There are so many articles- not just from fat-acceptance activists that make it very clear that BMI does not always correctly reflect the “health” of a person, infact it isnt even a good measure of whether someone is overweight or not. There are people who are considered overweight who have a very healthy lifestile. I am constantly on the verge of underweight, and my lifestile (junk food eating habits definitely included) is not very healthy at all. This policy, by making BMI the first measurement, buys into the false equivalency of “fat” and “unhealthy” (there is also the problem of the margin of what is considered to be a “good” BMI becomming more narrow over time). This is discriminatory towards fat people and it also excludes thin or “normal” people from the ones encouraged to better their health. It is not a policy that encourages healthy behaviour, it is one that demands thinness – especially worrysome given how many weight-loss measures can be extremely detrimental to people’s health (never mind the fact that they don’t work)
I agree that, to improve the health of all workers, improvement of working conditions including better meals would be a better way to go. Or encouraging all workers to partake in exercise that their ability status allows, and comp part of the costs for that. But then, that would require the corporations to invest money, instead of making people pay for not fitting into their definition of “healthy”.
This post seems a little bizarre. Not that it’s off-base, just that it seems to focus on one of the smaller harms that could occur, kind of like saying we shouldn’t go to war in Iraq because of the strain it will put on VA hospitals. It’s true, but…
I would say that the primary harm to fat people from the Affordable Care Act is this:
by increasing the societal role in health care, and specifically by requiring people to share their risks whether they want to or not, the law both legitimizes and valorizes busy-body peer pressure on health topics. It no longer solely matters whether being fat is bad for your health; now it matters that most people think it does, and see every fat person as a walking increase in their own insurance premium.
When my health care is my problem, my weight is my business. When my health care is YOUR problem too, then my weight – and every other aspect of my health – is also your business. It’s not just weight – smoking, danger sports, drug use, drinking, nutrition – all of these things are now EVERYBODY’S BUSINESS.
Most health elements are somewhat invisible to strangers. Unless you’re standing next to me on a crowded bus, you probably don’t know whether I smoke or not. You have no idea whether I spend my weekends parasailing off of volcanos or sitting quietly monitoring my blood sugar. Am I a stoner? A cokehead? A drunk? Again, unless you’re with me while I’m doing it or see me at the liquor store, you have little idea.
But everybody can tell whether I’m fat or not just by looking at me. And if I’m fat, and everybody thinks that fat people have bad health and run up health care bills, and everyone is responsible for my health care bills – well congratulations, now everyone fucking hates me worse than they already did.
THAT’S the harm to fat people – giving bigots a bona fide reason to validate their prejudices.
This trend has been going on in the private sector for some time. My last employer, for several years now, has charged smokers an extra $50 a month on their premiums. I remember being at the benefits meeting the first year they did this. Someone asked if we should expect, in the future, to see higher premiums for people who eat fast food more than X times a month or people who had other risky behaviors, and benefits manager doing the presentation just laughed it off as all the employees looked at each other nervously. But I see employer-based insurance moving in this direction with or without the Affordable Care Act, and work still is where most people get their insurance.
When I left that company, they still hadn’t added anyone other than smokers to the “pay-more” group, but the policy had engendered a certain amount of distrust among the employees. The last year I was there, they changed a number of things in the structure of the insurance policy to promote prevention – making all preventative visits free to the patient, for example. As part of this, they offered free screenings at work for any interested employee – blood work for cholesterol and blood sugar, etc. In theory, this was a great idea – you don’t have to take time off work to make an appointment, get a referral to a lab, take more time off to get the blood work done. You get the results there and can take them to your next annual physical to discuss with your doctor.
If you did the screening, you got a discount on your premium – no matter what the results. The idea was that if you found out you had high cholesterol, you could take action now, before you had a heart attack, and that would benefit everyone. And it was supposed to be totally confidential, and neither the insurance company nor our employer would know the results. Sounds pretty good. But a lot of people skipped the screening because they simply didn’t believe the results wouldn’t be used against them. Maybe not that year, but in future years, they were convinced that people with high cholesterol, high blood sugars, whatever, would end up paying more.
It seems to me that you could create incentives for healthy behavior/habits without directly linking it to premiums. If the programs work, people will be healthier, which would keep premiums from going up as quickly (I don’t really believe they’d go down), so individuals still would see savings. I haven’t thought this through enough, but I’m wondering if it would work better to target incentives toward companies (if you reimburse a gym membership or create a work-out room at the office, you can write that off, or something like that) than toward individuals.
Amanda, I think that my employer’s tracking of how many times I go to the gym is damn privacy-invasive. Also, consider the liklihood that since this is a government-run healthcare system that information will end up in the hands of the government. It’s nobody’s business but mine and the gym owner how often I go to the gym and what I do there.
My plan contributes $100 to my HRA (and another $100 for my spouse) if I answer a health assessment questionnaire once a year. They ask all the questions you might expect; do I smoke, what do I eat, how much do I exercise, etc. Then they make recommendations on what I should do to improve my health (don’t eat things I like to eat, eat things I hate to eat, go get a cholesterol test dummy, etc.). That’s bad enough. Tracking my behaviors is definitely off-limits.
Where does it stop? Charging smokers an extra $500/year? Checking my credit cards to see how often I go to McDonalds? Robert’s right. We are opening the door to making personal behavior public business.
Good idea. In theory. I approve of this. But what happens is that it gets shot down because too many people think that it means that you approve of drug use. How often have we seen distribution of condoms get shot down because it’s seen as approving of sexual activity? What aspects of these plans end up giving the voters a voice in individual behavior?
What’s a CSA?
CSAs are programs that are set up between farmers and customers. The customers pay an upfront fee that’s usually discounted from what you’d pay at the farmer’s market or even grocery store, and the farmers give you whatever it is they harvested that week. The tradeoff is that you can’t control what you get. But what it’s good for is motivating you to cook more—you don’t want to waste the food, so you learn recipes to use it in. And once you start cooking, you often realize it’s actually not as time intensive as you’d think. Meal planning is the worst part, and that’s often taken care of for you if your ingredients are chosen ahead of time, a la Iron Chef.
Well, in this, no one would be forcing you to go. You could opt out and simply forsake the reimbursement. I’m not staying up at night because someone at HR knows how often I go to the gym.
Where does it stop? Charging smokers an extra $500/year?
Did you see my post, Ron? This already is happening and has been happening for years.
The thing is, we know that punitive measures probably don’t work as well as incentives. But you’d think libertarians would be all about charging more to those who are higher risk, and smokers are definitely that.
I dunno, I take a dim view of these programs when they’re linked to the plan’s cost or the subscriber’s premium amount. Even with the “exceptions” I can see abuses happening–and the focus on thinness is just plain wrong-headed. I’ve said this about 100 times, but I’ll do it again and bore y’all–when I was in college, I was 20 pounds lighter than I am now. My diet consisted of Doritos and coffee. People assumed I was fit because I was thin. But I wasn’t fit and I wasn’t healthy. I’m in much better shape, and much healthier now.
My current plan offers a partial reimbursement of up to $150 a year for gym memberships–they don’t need to see a record of your attendance, they just need to make sure that you do indeed have a membership at the gym. Perks like that–and resources for healthier living–are always nice. Recognizing that there are holistic solutions to systemic problems such as food deserts/the grocery gap, safe and accessible spaces to walk and be active in neighborhoods, etc. is also helpful. But tying this stuff to the premiums? No. Just, no.
Invasive! What’s next? Penalizing me for watching TV (sitting on the couch) instead of doing yardwork? What about bicyclists who ride without helmets? What about people who bungee jump for fun? “I’ve got a little list….” Married women have worse health than unmarried, does that mean I can get a premium break if I get a divorce? Of course, married *men* are healthier–does that mean if I sacrifice my own health to keep a man healthy (by marrying him) I’m an altruist (and can I get a premium break for that)?
What about the kids who like to read books more than play sports, do they (or their parents) get penalized? Is there really only one acceptable kind of life to lead, with a perfect balance among activities planned to maximize utility and minimize burden to other people? Am I really supposed to make all my life choices with the sole metric of whether it will make my medical costs higher to others?
If you aren’t going through an employer, they do charge you more or less based on certain factors. Same with car insurance—married people are better drivers on average, so they do get a break. This isn’t something they’re starting to do. They’ve always done it.
Amp mentioned in the OP that he is not insurable on the private market. Robert, since you previously defended insurance companies refusing to sell policies to women who have had previous c-sections, I’m assuming you’re fine with insurance companies refusing to sell policies to fat people or anyone else they deem unhealthy/too risky. What we have here is a policy that makes coverage available to a lot of these “too risky” people, with some policies that raise the possibility of significant discrimination in pricing.
It’s simply not true that before your health was only your issue and only now is this becoming a social issue. The difference is that because the government is involved in this process, people have the opportunity to influence what the final policies look like. Changing the incentive structure to not overly penalize fat people is, indeed, an uphill battle, but at least there is the opportunity for input. In the status quo, there simply is no way for people to influence insurance companies enough to change their policies.
I don’t go to gyms. I have expensive exercise equipment at home. Exercising in public as a fat person? Not lots of fun, and seriously potentially problematic.
Besides, I think we should be encouraging people to do things like hike, which are actually fun, and not confining the exercise experience to the gym.
Mandolin, exactly.
I don’t have a gym membership. I don’t want one. The last time I joined a gym, I got bullied into accepting “nutrition counseling” that put me on a restricted-calorie diet, a package of “personal training” with a guy who wouldn’t give me exercises for my abs because “they’ll bulk up and that upsets women,” and after spending 6 months, 4 days a week at the gym, on this restricted-calorie diet, I hadn’t lost any weight and got de-motivated and depressed. That was before I found HAES and gave up dieting.
I strongly suspect it is linked to the reason that my (previously stable) weight suddenly increased by 30 pounds a year or so later, and that giving up dieting is why my weight has, since then, remained stable.
Now I get my activity on my own terms. I take dance classes, go out dancing, walk around the lake in my city, do yoga and stretching and dance drills at home. I have no desire for a gym membership and no room in my budget or schedule for one. I have no desire to be around the fitness-obsessed, to experience intrusive personal comments from the “well-meaning,” or to give my money to any entity that promotes dieting and exercise for weight-loss purposes.
My employer was “affiliated” last year with a larger university system. Our benefits now come from the larger system. This week we all got an email titled “This Year’s Health Risks! Be Ready!” Apparently we are to expect that we will be receiving a link to a survey asking us for personal health data so our insurance company can “provide wellness recommendations” for employees as a group. Of course one of the datapoints they’re asking for is BMI. I already work hard enough to avoid toxic dieting oriented conversations at work without my employer spending time and money on “wellness recommendations” which will inevitably involve a weight-loss club, I will bet $100.
But hey, if I divulge my health information, I could win an iPad!
I am thinking of filling out the survey (which will also ask for cholesterol and fasting blood sugar info, which I happen to have) and seeing if I can skip the weight question. But I doubt it.
I had a friend in college who was very slightly overweight, and had been severely anorexic in high school. She was also a long-distance runner, and would from time to time work out on the treadmills and the ellipticals. People sometimes abused her, shouting things like, “Give it up. It’s obviously not working.”
I have not experienced that kind of abuse as a fatter person than she is. However, I am also someone who’s had problems with eating disorders. Can you *imagine* how triggering something like that is?
Jesus H. Christ. That always makes me think of how much I hate it when I hear a dude mocking a fat woman for drinking Diet Coke. I haven’t heard that “joke” in awhile, but it used to be something you’d hear a lot, as if the right to skip the sugar was earned by being skinny. It didn’t even make sense.
Elusis – do not fill out the survey. This is something insurance companies like to have to jam up your ass later if you have the temerity to actually ask them to pay claims like they’re supposed to.
mythago – the irony is that everything other than my BMI would indicate I am in excellent health. I hate to feed into the “good fatty/bad fatty” dichotomy by flogging my health numbers, but my cholesterol is well-balanced, my thyroid is healthy, my blood pressure is low, and my fasting glucose is ideal. My level of physical activity is lower than I’d like of late, and I’m trying to decide how best to deal with some loss of general strength, but the variety of vegetables and whole grains in my diet is outstanding. And the insurers have most of that data already since they paid for my bloodwork last year. What they don’t have is my weight. I’m on a group plan, and I routinely decline to be weighed at the doctor’s office unless there is a clear medical reason for them to do so (I don’t care for doing irrelevant medical tests.)
We shall see what we see about the privacy language that comes with this survey when it’s released June 1.
I understand the argument, but this is happening already, as any fat person can attest. The public shaming occurs despite the fact that fellow bus passengers shoulder no responsibility for keeping their fatter brothers alive. It also has nothing whatsoever to do with actual health or healthy behavior, which makes me think that it will continue independent of a fat person’s relationship with individual or collective health. I don’t see why healthcare reform would make that much of a difference to a problem of hatred.
Can someone from any other developed country chime in? Has the National ‘ealth created a climate of demeaning interference for rugby teams, or decreased the social status of coke fiends?
This is a fascinating discussion for me to witness. I feel a bit like I’m listening in — I am one of the people who works for a wellness program, a publicly funded one.
I’m in agreement with Amanda Marcotte, and the approach we take is one that emphasizes what employers and worksites can do to support employees — creating a healthier work culture — including offering CSA delivery at some worksites. We are in a position to encourage rather than enforce, and I will quit my job the day that BMI and other health outcome measures are used to determine cost-sharing by employees where I work. I have fought long and hard since I started at this job to be a voice against using BMI as a measure of much of anything. Ironically, when I first took this job I didn’t feel like I was making much of a difference, but these days, I feel like I’m fighting to make sure employee’s rights are protected.
Much in the way of better health, more vitality and lower health care costs for individuals, in some cases, and entities paying for the health coverage, in even more cases, could be accomplished without massive invasion of privacy and some good safeguards in place.
The problem with the law is the leeway it allows. Ultimately, there will be employers with amazingly talented workers with higher health care bills — and employers who choose who to hire and keep based on how much the health care bills are/will be. Guess which employers will perform better at their businesses? The employers that refuse to charge more for health coverage for their talented-with-risk-factor employees may end up offering crappy health insurance and pay their employees higher wages, and then their employees can buy their own insurance in an exchange or buy into the public health plans — and over time, employer-based insurance will become obsolete.
While health coverage from the employer is theoretically terrific, the health care delivery system is so messed up that there could end up being much better health care options that are less expensive out there.
I’ll shut up now — I have a million things to say about this. Great starting for discussion. I think that wellness programs could be great for fat people, and not fat people as well, but they will in many cases but employers and employees at odds with each other in ways that will only hurt.
One potential great thing about being able to afford (and be eligible for) some kind of health coverage without a job — more entrepreneurs. Which means that some people in salaried positions who were there just to have the coverage can leave and pursue what they really want to do — and unemployment can go down. I know it’s not that simple, but it is part of the picture.
When my health care is my problem, my weight is my business. When my health care is YOUR problem too, then my weight – and every other aspect of my health – is also your business. It’s not just weight – smoking, danger sports, drug use, drinking, nutrition – all of these things are now EVERYBODY’S BUSINESS.
Only if you want to make it so. With a sufficiently large pool of insured, everything will cancel itself out with no snooping into personal lives, and you’ll save a metric shitload of money on bureaucracy and informers. No one has a right to cash in on their luck, IMO. If someone feels that they are not getting their money’s worth from their health insurer, they can always take up skiing, DIY, or playing soccer.
I have, from a health insurance POV, horrible genetics. All women in my family survived all the ailments that befall the elderly until they were in their 90s, no matter if they were into healthy eating and exercise, into buttercream and reading all night, if they were chain smoking party animals or abstinent introverts. If my health insurer was free to adjust rates in accordance with expected costs, I’m sure they’d *love* to charge me extra on the base of this alone, or maybe encourage me to take up bungee jumping as a hobby.
piny, I’m in Germany. My health insurer used to re-imburse part of the costs for the gym or any type of health class. At the moment they pay only for classes through affilated gyms and teachers, though. I feel that reimbursement, quality control and encouraging gyms to offer classes at convenient times (and with child care) is the best that can be done. There are also employer-sponsored actvities like bike-to-work clubs, walking clubs and the like, which have not cash incentive (though you get badges and trinkets). Wellness programs are always costly in terms of time, effort, and (usually) money, so reducing that cost lowers the barrier to do one for people who are basically motivated. IMO, with people who are not motivated, attempting to force them is contraproductive: It makes everyone involved stressed and bad-tempered which is not good for anyone’s health, and gives wellness programs a bad name.
There is still stupid happening. At my health insureres fitness test I regulary fail because it is less important that my grip strength is off the scale and that I can schlepp two suitcases full of books up three stairs to the attic than that I cannot jog for 30 minutes (nor for 5, in fact). But that has no consequences but getting junk mail from them.
It’s ironic that in Ontario, which has a single payer health care system, there is less emphasis on weight than in the US. People here don’t look at health care as a commodity that you’re more deserving of if you behave certain ways or are thin. You rarely hear the idea that some types of people are dragging down the system. It’s seen more as a universal right. And I say this as someone who’s worked for 6 years in Ontario and for 14 years in Michigan. It’s when the system isn’t the same for everyone that people start pointing fingers and asking for special treatment.
As far as I’m concerned, as long as I’m physically capable of doing my job, my health and habits are none of my employer’s business. They can fire me at any time, and I can leave at any time. It’s at-will employment, not a long term, committed relationship. If I have to take it or leave it, then so do they. Bottom line.
I’ve noticed how discussions of health care costs often mention the cost of obesity-related illness. They never seem to mention the cost of eating disorders. They never seem to mention the cost of orthopedic damage related to inappropriate or excessive exercise.
The weight-loss industry has very strong PR. They attribute X cases of heart disease, Y cases of worsening arthritis, $Z to treat it all, to obesity. I don’t think anybody is even counting all the costs associated with eating disorders.
Yup.
I’m fit enough to qualify for the nearest SWAT team. My resting pulse, stress pulse, HDL, LDL, all check out within acceptable norms, whatever those are. No one, in my life, has ever told me or suggested that I was overweight. But when I plug my numbers into a BMI calculator, I’m told that I’m 8 to 15 pounds into the “obese” category. It’s absurd.
Yes, there’s the standard disqualifier that BMI may not work well for athletes, but that’s pretty silly when you’re basing dollar decisions on a faulty measure, and you have no way to distinguish athletes from non-athletes.
Part of it is the math: the idiot who invented BMI did not understand that human beings are three-dimensional, and thus, the term for height in the equation needed to be squared, not linear. There are actually BMI tables out there based on better math. But I’ve never found one in actual use by an organization which makes dollar decisions.
However, the bigger problem is that BMI is simply not a good indicator of health, for many reasons others have already covered. The main reason that it’s used, in my opinion, is that it’s easy. Frankly, we don’t understand health, overall, very well.
Grace
Yes! Under those plans, I get no credit for hiking out my front door, running out my front door, running at work, doing free weights at home, doing free weights at work, practicing a martial art at a location not fitting the organization’s definition of a “gym”, etc.
Grace
I do think the reasoning is that athletes with so much muscle mass that they’ve got super high BMIs are such a tiny percentage of the population that they don’t influence the actuary tables. Insurance companies don’t care about individuals, anecdotes, or exceptions to the rule. They aren’t writing an infalliable Bible, where one error ruins the whole system. If their predictions are right 80% of the time, that’s a really good rate, as far as they’re concerned.
That’s true, and I understand their perspective; no skin off their noses as long as they get it right most of the time.
Of course, the individual perspective is exactly the opposite. If we are rewarding based on BMI, and being a healthy athlete puts you into the “obese” category for actuarial purposes, there’s an undesirable outcome for the individual.
I don’t intend to sound like I’m bitching, here; I know that I’m very fortunate, and that in the grand scheme of things, this is small potatoes. But I’ve seen some heroin addicts who would qualify easily for “lean”. As a design geek, it offends my sense of fairness and elegance that insurance companies are basing decisions on such a measure which is demonstrably deceptive.
Not that I have a better easy solution, mind you. All the solutions I can think of are a lot more complex, and all have their problems.
But that doesn’t make me like this one any better.
Grace
I don’t disagree. I think the problem is that these discussions get overwhelmed by the exceptions, and if you think reducing costs is important—and it is—the “but 1% of people with a BMI over X are just really muscular” comes very close to special pleading.
If we think that controlling costs or risk management shouldn’t matter, we will never even get a hearing. There has to be a balance; the argument is how to strike it.
Well THERE’S your problem.
http://junkfoodscience.blogspot.com/2009/10/predicting-heart-attacks-government.html
http://junkfoodscience.blogspot.com/2009/06/even-obesity-paradoxes-cant-excuse.html
Assume the entirety of the “obesity paradox” series from JFS is pasted in here.
The idea of my employer having any access to my health care records and any role in deciding wether I should pay more or less than my coworker at the desk next to me creeps me out. But then, I’m Canadian. Health care coverage is considered a basic human right, and is written into our constitution. (from my cold, dead hands, indeed). I don’t understand why anyone is okay with your employer keeping track of when you go to the gym, or the results of your latest blood work.
Why should people in poor health be further penalized by paying more for coverage? They need the money to pay for medication and some treatments to make them better. They can already be facing lower pay because of days missed due to illness. (Unless the US somehow gives more sick days? I got three per year at my last job. Not nearly enough for anything more than a nasty head cold.)
I would much, much rather have my government have my health records, than the Human Resources department, and a private HMO. At least I have a vote to determine who is the government. And they never eye me sideways in the lunch room, checking out my plate.
Remember, from an insurance company’s perspective, asking why people in poor health should have to pay more is like asking why people who get in to a lot of car accidents should pay more for car insurance. It’s not really baffling why this happens. If you want to argue that it’s simply so unjust that it shouldn’t happen—and I agree, health is different enough that it should be a matter of rights—you can’t be indifferent to the need to control costs. If everyone thinks that the price of justice is costs spiraling out of control, justice arguments will fall on deaf ears.
Absolutely, and this is why healthcare should have nothing to do with insurance as we think of that concept in every other walk of life.
We all would love to buy into the notion that modern Western societies are meritocracies. One of the best counterarguments I can think of is the American health insurance system. What is your health, if not a vast roulette wheel? Any of us could get permanently injured in a car accident, disfigured in a fire, or suddenly develop all sorts of health problems, at any moment. The results of that will vastly affect the rest of our lives, and generally for the worse, including the result that medical coverage becomes close to impossible. And yet, our society wants to act as though we earn everything we get.
If we really wanted success to go to people who work hardest, who earn it the most, we would level the playing field as much as possible when it comes to things beyond human control.
Instead, we have the vast betting scheme which is American “health insurance”, which favors those wealthy enough to buy their insurance, or privileged enough to have it included as part of an employment package.
Grace
The need to control costs doesn’t mean any purported attempt to control costs, is actually that, or indeed does.
A lot has been made of screening as preventative and cost saving, the actual results are mixed.
But a lot of the reasons why costs are spiralling out of control are the medical model itself, which goes unquestioned while fat people and others are falsely set up to take the fall.
There are a lot of procedures that have been swallowed up by it, unecessarily, but cost cutting measures often overlook this in favour of two incompatibles, keeping professional status intact, whilst increasing the amounts people do for their health.
I don’t know about the US, but here in the UK, the National Health Service spends more on those who are too thin, than those deemed too fat.
They pick on fat people because stigma permits them to profiteer, not purely on the basis of actual costs.
They decided to cover gastric bypass and all sorts of “slimmng drugs”, why did they if they need to control costs?
Grace, I think your comment speaks to what’s wrong with the idea of a meritocracy in the first place. After all, we all kick the word around without talking about what we even mean by “merit”. In the past, being of sound mind and body was considered a minimum standard to consider someone meritorious. That’s why fighting for the rights of the disabled was so hard. Now we accept that it’s worth it to build wheelchair ramps and other accommodations, even though they do cost money.
Even if we were able to get a health care system that wasn’t about profits and had ways to control spiraling costs—and believe me, I don’t think this system we just got is it—there is still going to be concerns about saving money. Ideally, we don’t overtax people to pay for health care. Centralized systems are no cure for seeking wellness initiatives that make people feel judged. If you don’t like your employer knowing how often you work out, think about the British system where why pay doctors more if they can get their clients to adopt steps towards preventing bad outcomes down the road, like quitting smoking or taking up exercise.
Personally, I think that in most regards, focusing on prevention as a cost-cutting mechanism is a win-win situation. The money people win, and the clients win. I’m glad I get a reimbursement for some of the costs of my gym membership. They win by getting into habits that will probably save them money, and I win because I don’t really want to get sick down the road either.
Amanda, could you stop talking about “people in poor health” as if they were synonymous with “people with higher BMIs”?
Duplicate comment deleted.
Did I? I don’t recall doing so. Obviously, that’s not true. But if you could find a direct quote where I equate the two, that would be helpful.
Amanda,
Earlier, in response to Grace saying that BMI was a bad measure because she’s super-fit yet qualifies as obese, you said
So you seemed to be saying that insurance companies predictions, based on BMIs, might constitute a “really good rate” of correctness, since they’re still using BMI despite its tendency to describe those with high muscle mass as “obese.”
You further clarified this point, saying
So what you seemed to be saying is that using BMI as a way to predict health is a way of reducing costs, even though a few people with high BMIs don’t fit the “profile” of what we consider to be obese people. The unstated assumption in Grace’s comment, that you don’t seem to challenge, is that muscular people are healthy by definition, and have low costs to insurers, while “true” obese people have high costs to insurers.
In response to your “If [the insurance companies'] predictions [about the relationship between BMI and cost] are right 80% of the time, that’s a really good rate, as far as they’re concerned,” I posted two links, one showing the failure of a “risk factors” profile in predicting heart attacks, and one discussing the “obesity paradox,” in which overweight and obese people showed a lower risk of dying, and “morbidly obese” people showed the same risk of death as “normal weight” people.
Two comments later, you respond to someone, it’s unclear whom as you didn’t quote anyone, saying
What your comments read like, taken together, is that your position is
- It makes sense that insurance companies would profile risk as a means of controlling costs.
- BMI may get some super-muscular people classified as “obese,” but insurance companies are profiling according to the general rule, not the exceptions. This statement contains the assumption that “obese” people who are largely muscle are different in their risks from “obese” people who have more body fat.
- If a profile for risk is mostly accurate, it makes sense for insurance companies to use it despite the fact that some people are exceptions.
Given that insurance companies DO use BMI to create “risk profiles” for the purpose of denying people insurance, charging higher rates for insurance, denying medical procedures, etc., you appear to be arguing that their use of BMI as a reference point for developing risk profiles makes sense because, although it may sweep up some muscular athletes as “obese,” the majority of “true obese” people do indeed represent a higher risk.
As the topic of this post is “how fat people will be harmed by the ACA,” and one of the harms articulated is that fat people may be charged more for their insurance because of employer’s “wellness” pricing schemes that use BMI as one point for determining “wellness,” your statement that “asking why people in poor health should have to pay more is like asking why people who get in to a lot of car accidents should pay more for car insurance” comes off as equating fat people with people in poor health. You seem to be arguing that it makes sense to charge people more for insurance if they’re in poor health, in response to a post and discussion about how fat people are likely targets for increased insurance costs.
In addition, Amanda, you’ve also demonstrated a rather dismissive attitude toward Health At Every Size, accusing it of “cherry-picking scientific evidence to fit an agenda” (a description that better describes the ZOMGOBESITY, bariatric-industry sponsored studies) and have decried “tear[ing] at the link between obesity and poor health outcomes [sic] or… at the link between calorie consumption/exercise and obesity [sic].” In that same post you state that “obesity is a public health concern.”
So, you’ve said as much elsewhere.
I’m pretty much with Meowser here.
Elusis writes:
Pretty sure I didn’t say that, and if you inferred it from what I wrote, well, I guess I can’t control that.
I was seeking to demonstrate that BMI is a poor measure of health. Rather than use a hypothetical or point a finger at anyone else, I used my own experience. Many of the measures I cited have nothing to do with muscle. Although I did assert that I’m fit, I did not take credit for my health. In fact, later on I pointed out that I am very fortunate, and then I argued that ill health has a great deal to do with fortune.
So much for what I wrote. Since you are reading meaning into my post which I don’t think is there, let me clarify my actual opinions.
I know a number of people who would be classed by our society as fat. Some of them are strong and apparently healthy. Some are not especially strong but apparently healthy. Some are definitely not healthy. Many of them have worked hard to reduce weight, and some of the most determined have failed. I know one woman who is very thin and has been ordered by her doctor to use cream instead of milk in order to maintain her weight, even though she does not exercise.
Clearly, weight is complex, and by itself a poor measure of health.
Since BMI is a measure of weight, modified by height, it is also a poor measure of health. See my example as further argument.
Some measures of health which are arguably more accurate are functional strength and aerobic capacity. However, as we learned from Jim Fixx and any number of others, very fit people can drop dead for reasons unknown prior to death-and-autopsy. Death is not the only possible outcome; any of us can look healthy by many measures, and turn out not to be. I know a person whose biceps tendon simply snapped one day. He was not lifting a particularly heavy weight. It was just the tendon’s time to go. Good thing he had “health insurance”, because on that day his health landed on a bad number on the roulette wheel.
To the extent that our health IS in our control, the control levers would seem to be regular moderate exercise (with additional benefits dropping off as you add exercise) and good nutrition. Beyond that, you get into more hazy territory. There’s some evidence that you can extend healthy life, “square the [mortality] curve”, with optimal nutrition and extreme caloric restriction. However, even if that turns out to be true in humans, that does NOT permit us to infer that eating adequate nutrition and being “overweight” will modify the curve in a bad way.
So, getting back to the topic at hand, if we are trying to make the population healthier, we should have incentives to encourage moderate exercise and nutrition. Nutrition is very hard to measure without extensive monitoring, so the low-hanging fruit is whether or not people exercise, and the lowest-of-the-low is a gym sign-off. I don’t like gym sign-offs much, for the reasons I stated above in a different post. But I can’t think of an easier, lower-cost, way to create incentives toward health, overall, than gym sign-offs. Anything else will probably be more invasive, and more expensive to monitor. And then we’re back to rising costs. It’s a pickle.
There. If you’re going to put words in my mouth, you have a little more to go on.
But, I’d rather speak for myself.
Grace
Thanks for clarifying your thoughts, Grace.
Frequently, when people protest “but BMI sweeps athletes into the obese category along with actual fat people!” it sounds sort of like fat advocacy but scratch the surface and what you come up with is someone who still believes that muscle = healthy and fat = unhealthy (and un-muscular). The objection is often to these “faux-bese” people being unfairly tarred with the obesity brush.
I appreciate you taking the time to explicate what your beliefs are, and am glad that you see yourself as an ally and advocate.
I still feel like Amanda was arguing with an assumption that you were saying “BMI = bad because athletes get mis-labeled” in her comments defending insurance industry use of BMI as a sort of “good enough” data point, particularly since she has a history of pooh-poohing HAES and asserting that the only way to uncouple weight from health is to game the statistics.
Ah, I disagree that using weight to predict health outcomes is different than saying “all fat people are unhealthy”. I suppose that’s a fine point, but isn’t that the point? Insurance companies want to figure out *who* will get sick, not just who is already sick.
And even if you wish to deny that obesity is the cause of or related to poor health outcomes like heart disease or diabetes, there’s a correlation there that interests health insurance companies. A lot of stuff that goes into actuary tables could be argued to be correlation and not causation. Like, for instance, marriage and accident rates, which insurance companies take in to consideration.
My point isn’t to open the can of worms about whether or not obesity causes or is related to diseases like heart disease and diabetes. The point is that insurance companies—any health care system really—is interested in finding ways to cut costs. And that has to be balanced with human rights. And NO one is denying that better diet and more exercise cut long term costs in health care spending, by reducing levels of heart disease and diabetes.
My question is really how to strike that balance. I do think measuring and penalizing BMIs is a bad idea, but I think we can’t just write off wellness initiatives altogether. Everyone pays more if there’s no attempts whatsoever at cost control.
I’d like to see wellness programs that are more about what corporations and employers can do to create a more healthy environment.
For instance, how about tax breaks for companies that make standing workstations, and treadmill workstations, available to desk workers and cashiers who want them? Or that build an exercise room available for free use by any employee, and provide break time during the workday for exercise? Or tax breaks for building and maintaining a cafeteria that serves healthy food?
Hell, how about paid breaks, in addition to the usual lunch breaks, for employees who want to take a 20 minute walk twice a day?
There’s a lot we could do to create healthier work environments — and a lot of experts, for what it’s worth, argue that environmental change does more good in the long run than other sorts of changes. But so far, “wellness” programs seem designed more to place extra burdens on employees, rather than asking corporations to change what they’re doing.
That said, “opt-in activity” wellness programs, flawed as they are (I’m another person who prefers to exercise at home rather than in a gym) are certainly better than “be under X BMI or pay more for your insurance” wellness programs.
I think that’s really getting to the heart of it. Hell, standing workstations may not do much for the heart rate, but they’re useful for preventing certain diseases that can be caused by sitting around a lot, like deep vein thrombosis or hemorrhoids.
I have heard, anecdotally, about companies where non-smokers argued that they should get as much break time to go for a walk as smokers got. When I was doing office work, I tried to make a point of a short walk at least as often as a co-worker down the hall who smoked.
While we’re on the topic of addictive behaviors which are unquestionably bad for your health, I’d be behind free tobacco-use cessation programs.
One of the problems with exercise room is fear of liability. Where I used to work, someone proposed building one, and the immediate concern was “are we liable if someone gets hurt lifting weights, or falls off the treadmill?” It was a serious stumbling block, in the minds of the administrators. However, it should have been surmountable, in my opinion. A reasonably safe space, and signed waivers, and I would think you’re good to go. But what do I know? I’m not a lawyer.
I agree that providing free facilities, and access to nutritious food, and so on, is an excellent way to motivate good health, and positive rather than punitive, which helps create a better working environment, which leads to … lower stress. Which leads to better health, better employee retention, etc.
Grace
I think Amp was probably referring to treadmill workstations, where you have a U-shaped or C-shaped ergonomic workstation, and you walk at about 1-2 mph on a treadmill, instead of sitting. Essentially, it’s a slow stroll, but continued through much of your work day. The benefits turn out to be substantial.
Grcae
Wow has this discussion got weird – now we’re thinking as if we’re insurance comapnies? That’s a super-progressive starting point.
The question is surely what is the end goal? In New Zealand, health care is paid out of general tax revenue, and how much you pay depends on your income, not anything to do with your body. That’s how I think health care should be funded.
Unless you think people should be paid different rates for healthcare depending on their bodies, then say so. Because if you disagree with penalties relating to people’s bodies, then whether theyr’e 80% or 100% accurate is moot point.
This whole ‘health problems are created by people’s lifestyle, and therefore we need super targeted incentives and penalties to make people do what we want them to’ approach is one that I am opposed to. From a generally excellent
article by Pattie Thomas
Suggestions like treadmill workstations still take this sort of individualistic approach, and are still narrow one size fits all of what ‘health’ is . A much more progressive public health approach is to accept that the more resources (and here I mean time, money, transportation, access and so on) people have, the better they’ll be able to manage their competing needs. As I believe that people are competent to balance their long-term health needs up against their other needs, I think ensuring people have more resources, particularly time, but also money and access is far more important than micro-managing the things you think people should be doing.
Given that very few places in the US even have legally mandated sick leave, advocating for the right to work on a treadmill seems like a pretty fucked up priority to me.
I think a further example of the danger of indivdiualist rather than strucutral analysis of health problems is: “And NO one is denying that better diet and more exercise cut long term costs in health care spending, by reducing levels of heart disease and diabetes. ”
Which renders completely invisible those for whom more exercise is actually damaging to their health. There are a large number of health conditions where exercise is going to make things worse. The idea that everyone needs more exercise is specifically damaging to these people, as often they have to deal with constant messages that more exercise will help (including the ones in their head). Adding more to that message, rather than focusing on the fact that bodies are different treats damaging one group as acceptable collatoral damage.
BMI may get some super-muscular people classified as “obese,” but insurance companies are profiling according to the general rule, not the exceptions. This statement contains the assumption that “obese” people who are largely muscle are different in their risks from “obese” people who have more body fat.
Hold the phone. There’s a myth that in order for the BMI to be inaccurate for a person, they have to be “super-muscular” or an “elite athlete”. Not true. All they have to do is work out moderately. Take a look at the chart. A person who is 6 feet tall and 206 pounds is shown as overweight. That lumps the majority of male recreational exercisers or amateur athletes of that height in with the couch potatoes, or at least the ones who either lift weights moderately or have a physically-oriented job. As a short woman, I’ve never tipped the BMI scale into the “overweight” category, but BMI is more “generous” for women and shorter people (unlike the old-school height/weight charts that used to assume women had no muscle mass).
BMI isn’t a very good predictor of body fat percentage. Body fat percentage isn’t a good measure of health.
the “but 1% of people with a BMI over X are just really muscular” comes very close to special pleading.
Where did you get that 1% figure from, Amanda? I ask because I know a hell of a lot of men who tip the BMI charts as “overweight” even though they aren’t. Granted, most of the people I know are in the trades (and the office workers I know I tend to know from the gym or dojo!), but from my anecdatally-informed perspective, I’d say the number is more like 15% than 1%. Fifteen percent may not be the majority, but a measuring tool that is wrong 15% of the time is not a good tool to use.
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The idea of opening up my medical file to my employers gives me the willies, and frankly, it should be illegal for them to demand that in exchange for a fair price on insurance.
I am someone who could probably get a “medical condition” exemption for being fat; my general practitioner, my OB/GYN, and my psychiatrist all freely acknowledge that Remeron causes hella weight gain (in fact, it’s often given to people with wasting illnesses for exactly that reason) and that it’s almost impossible to lose weight on this drug. And on top of that, I have PCOS, which makes it even more unlikely (and also means I will extract the maximum amount of weight gain from any drug that fosters it).
But do I really want to have to tell the people at my company that I’m on meds, and which ones? I work at home and they hired me remotely, thus have never seen me; therefore, they don’t even know I’m autistic (I was diagnosed after being hired), or at least have never let on that they know. I certainly have never told them. I wouldn’t lie about it if asked, but why tell them more than they need to know? They don’t have to watch me stim, or freak out about how many times a day I take a crap or about my frequent (if brief) catatonic spells.
Depression is something easier for people to understand than Asperger’s, but truth be known, I’m on FOUR different brain drugs (one of them only used rarely for severe anxiety). Two are controlled substances, and one of them is dextroamphetamine (used to counteract the appetite-stimulating and soporific qualities of Remeron). It’s a very low dose of dex and I’m very careful and conscious about how I use it, but still. Do I really want to have to explain all that to my bosses? Having a crazypants on their staff, regardles of weight, might very well freak them out more than having a fatass.
Oh, and about “wellness” programs, agreed that many employers seem to think it means “weight loss” and nothing more. My own employer kicked off their wellness program not with a vegetarian recipe exchange, or a find-your-own-exercise-bliss program, or a stress management initiative, any of which might actually help people be healthier. Nope, they kicked off with a “Biggest Loser” contest. Good thing they can’t see me, and I don’t have to explain why I think crash dieting is about the worst possible idea for a fatass.
(And speaking of stress management, wouldn’t people be more stressed out having to pay extra for insurance? That can’t be very healthy.)