Shortly after I arrived in the US, I was dining in a bistro in New York City when the lady at the adjacent table dropped her menu. Normally this is a non-event, but I couldn’t help noticing that she was so large in the mid-section that she had great difficulty bending over to retrieve the menu. As I leaned over to pick it up for her I saw that on the other side of our table a bronzed couple was sitting down, chiselled physiques as if they had just temporarily stepped out of one of those underwear billboard ads. Each table seemed to satisfy perfectly a certain European stereotype of the US, but experiencing both at the same time was quite confusing.
In the US, as elsewhere, unequal distribution of health drives a range of prevention and health promotion activities. One obvious reason behind these is the view that being healthy is a key part of enjoying life. Another, that a lower burden of disease means that a health care system can be run more efficiently. And for many, a healthy population is important for ensuring a productive workforce. Since in the US, the vast majority of health insurance is employer-based, the connection between these three rationales is especially close. Many employers have implemented a range of excellent workplace wellness programmes, and in the best case these result in a win-win situation, benefiting the workers, the company and the economy as a whole. But some initiatives, such as so-called “wellness incentive” programmes are highly problematic, and health reform plans threaten to make matters worse.
Under current regulations, insurers may offer financial reimbursements of up to 20% of the cost of healthcare coverage to those who meet certain health related targets. For example, for someone whose health insurance costs $4,824 annually, up to $965 may be provided in reimbursements if that person’s Body Mass Index, blood pressure or cholesterol is in the normal range, or if they don’t smoke. If provisions in the current Senate Health Bill are adopted into the final bill, even more may be available in the future, as it is proposed to increase the standard level from 20% to 30%, and to permit 50% paybacks in special cases (see here for some more background).
Being offered the option of paying less for your healthcare is, no doubt, great for those who effortlessly meet targets such as those above. And it’s good news for those who try hard, and succeed. But for those who try and fail, the incentive ‘carrot’ may feel more like a ‘stick’. The same is true for people who, for reasons that are beyond their control, find it impossible to try. This is especially problematic as those least likely to benefit from the schemes are typically also those most likely to be unhealthy. Yet, proponents argue that there is nothing unfair about this: for them, wellness incentives are just an application of a fairness standard of the car insurance industry, where it is accepted that good drivers should not have to support bad drivers with higher premiums. But clearly, personal responsibility, the social determinants of health, and voluntariness play different roles in driving and healthcare: choosing not to speed is, on the whole, equally easy for all, and in any case much easier than choosing to be healthy (and acting on it).
In the context of the current health reforms, wellness incentives must also be viewed critically, as they threaten to undermine the spirit of a key provision: one of the major steps forwards is to ban insurers from refusing coverage to people with pre-existing conditions. But to many, wellness incentives simply look like medical underwriting by another name, or, as Yogi Berra would have it, a case of ‘déjà vu all over again’. But fortunately, there is now a rising groundswell of opposition. Led by cancer, diabetes heart disease and stroke associations, more than a hundred patient advocacy groups recently voiced their concern about the programs and their impact on affordability and equity in a letter to members of Congress, and the lobbying machine is turning.
In the reconciliation of the House and the Senate health bills there are some fairly major issues still to be resolved. The cost of the reforms and arguments for and against a ‘Cadillac tax’, provisions on abortion services and the so-called public option will again be debated intensely. Wellness incentives may seem like a detail, but they could have drastic impact on the affordability of healthcare. There is a role for incentives in healthcare, but, as colleagues and I have suggested elsewhere, the current and planned proposals go in the wrong direction. Levels should therefore not be increased, and there needs to be close monitoring of how the current 20% rule is implemented, so that there is no inequitable cost-shifting in the name of wellness.
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