Thursday, December 6, 2007

Is Making Employees Pay for Bad Health Habits Ethical?

Employers are desperate about health care costs. Some are dropping health insurance altogether. Some are making employees put more “skin in the game” with increased deductibles. And some are starting to make employees pay for bad health habits.

A Harris poll reported in the Wall Street Journal in October showed that a majority believe that employers should not make employees who smoke, are seriously overweight, or do not exercise, pay more for their health insurance,

But starting next month, the Tribune Company in Chicago will charge employees who smoke $100/month. And the Kellogg Company is raising the premium for non union employees $360 for those who decline to take a health risk assessment. Other companies will follow their lead.

How ethical are programs like these?

I believe for a behavior like smoking that, while addictive, is potentially controllable, charging a small fee is ethically justifiable. The fee should be modest at the start. The aim is to attract attention and make the point that smoking doesn’t just harm ourselves – it taxes others by the health costs we generate. For that reason, the fee should be used to offset overall insurance costs. The $100/month the Tribune Company plans to charge would be punitive for most employees and seems too high. But the Tribune has addressed this by waiving the fee for employees who complete a smoking cessation course.

A teamster official who works for the Chicago Tribune asked “What are you going to do next? Say a guy who has history of heart disease has to pay more? Where’s it going to stop?” This is the right question. Charging more for people who are sick is not justifiable. But charging for a modifiable habit that contributes to higher costs for the whole group is.

We Americans worship financial fixes. What the Tribune and Kellogg are doing is justifiable if thought of as part of a broad attempt to help us recognize that we will only tame runaway health costs if we pull together as a population and self-prescribe some painful medications. A carefully planned charge for bad health habits can play a small part in the large educative process we need to carry out.


Unknown said...

Can you say more about how an employer should determine whether an unhealthy behavior is a fair target for financial penalties? For example, does eating to excess qualify?

Jim Sabin said...

Hi Richard

Your excellent question is crucial for the ethical acceptability of the employer practice. In my view, to justify using a "stick" to try to influence health related behaviors, the behavior (a) must be easy to define and (b) have a strong evidence base. I believe that smoking meets those criteria. Eating to excess, while regrettable for long term health status, and perhaps uncomfortable for the eater, does not. In particular, "excess" is too hard to define.

As I said in the posting, I regard this employer mechanism as most useful for sparking reflection on our mutual responsibilities to each other with regard to health care costs. I plan to do a posting on this topic in the next few days.



Anonymous said...

“Future ages will bring with them new and probably unimaginably great advances in this field of civilization and will increase man’s likeness to God still more. But in the interests of our investigations, we will not forget that present-day man does not feel happy in his Godlike character.”

-from Civilization and Its Discontents
by Sigmund Freud

I fear we have forgotten the valuable lesson in Freud's comment about our advancement in the field of health. Placing a dollar amount on "risky" behaviors has the dangerous potential to be the first step down a very foreboding path. The Chicago Tribune teamster official (cited in the original post) concerned about a financial penalty assessed to those with a chronic condition like high blood pressure may have more to worry about than he realizes.

A posting on Charlie Baker’s Let’s Talk Health Care blog last month touched upon this topic. The question of fairness was brought up by the posting, and the resulting comments reflected differing attitudes on the fairness, or ethics, of this practice. In making my own comment on the topic, I brought up the issue of genetic screening and testing. Playing devil’s advocate, I brought up the fact that evidence exists for making a case of a genetic predisposition towards adopting addictive traits, in this case smoking. The argument I bring up is, ‘how can one be charged more for a condition for which one may be predestined?’ Obviously, this (smoking) is an extreme case, but the point carries well into areas like high cholesterol, high blood pressure, and diabetes. How would an employer, insurer - or for that matter, anyone with ‘skin in the game’ – react if presented with data that specifically outlined a predetermined genetic risk carried by a segment of the target population? Could some one with a financial interest in the well being of the individual(s) be expected to ignore the presupposed inherent risk if the individual(s) in question is carrying a genetic indicator for diabetes?

I think it is extremely important that the dialogue on this topic continue, and with 2007 being a banner year for genetic research (see J. Craig Venter), I think this discussion needs to move from the blogosphere, to the dinner table – so to speak – in a hurry.

Here’s the link, by the way, to Charlie’s post:

Jim Sabin said...

Hi Ian --

I agree that advances in genomics create a whole new dimension to the issue of "responsibility for health." In all likelihood there are genetic predispositions to addiction. But "predisposition" is not the same as "predestination." For me the bright line in considering financial tools like the ones the Tribune and Kellogg are implementing is between health status and potentially controllable behaviors. If a smoker gets lung cancer we do not know the causality -- we only know probabilities.

As always, thanks for your thoughtful comments!