RESPONSE TO DR. CAWLEY

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Volpp, K. G., Troxel, A. B., Pauly, M. V., Glick, H. A., Puig, A., Asch, D. A., Galvin, R.,Zhu, J., Wan, F., DeGuzman, J., Corbett, E., Weiner, J., & Audrain-McGovern, J. (2009).A randomized, controlled trial of financial incentives for smoking cessation. New EnglandJournal of Medicine, 360, 699–709.

Volpp, K. G., Asch, D. A., Galvin, R., & Loewenstein, G. (2011). Redesigning employee healthincentives—Lessons from behavioral economics. New England Journal of Medicine, 365,388–390.

RESPONSE TO DR. CAWLEY

Morgan Downey

As before, I am only addressing the outcomes-contingent employer wellness pro-grams (EWPs) focused on weight-loss interventions that provide an incentive orpenalty for meeting or failing to meet a specific weight-related metric. The penaltycan be as much as 30 percent of the total health insurance premium, approximately$1,765 for average single coverage or $4,905 for family coverage. For both single andfamily coverage, this wellness penalty is more than the average employee contributesto group health insurance premiums (Kaiser, 2013).

Dr. Cawley and I agree that financial rewards have a mixed record. EWPs have notdemonstrated sufficient return on investment and, at best, induce only short-termbehavior change (Mukhopadhay, 2013). We agree that the body mass index (BMI) isa poor criterion. It can be overinclusive of persons who may not develop expensivecomorbidities for years, if ever, or who have high muscle tissue. Up to one-thirdof persons with obesity measured by BMI are metabolically normal (Bluher, 2012).The BMI can be underinclusive as well. Persons with a normal BMI and a highpercentage of body fat have high risk for cardiometabolic dysfunction (Oliveros,2014).

I would respectfully disagree with Dr. Cawley on a few points. I would not recom-mend that the Affordable Care Act (ACA) should provide more flexibility for healthplans in the design of EWPs. The legislative proposal to increase the size of theincentive/penalty permitted (from 20 percent to 30 percent of the health insurancepremium) was enacted on the basis of claims of success from the then-CEO ofSafeway Inc., which have never been substantiated (Downey, 2013). Studies to-dateinvolved volunteers and those produced little weight loss. We have no experiencewith employees compelled to participate in such programs. Studies on the durabilityof weight loss in EWPs are lacking. We have no experience with EWPs that providealternative routes to the reward and involve the employee’s personal physician.

“Obesity is a disease that continues to manifest itself in the form of decreasedenergy expenditure and increased appetite even after it has supposedly been ‘cured’by weight loss” (Rosenbaum, 2012, p. 16). Current EWPs have not demonstratedthat they can deal with this complexity.

A proposed rationale for EWPs is that they can reduce external costs, that is, coststhat arise when a person does not bear all the costs of his or her behavior. However,basing rewards on BMI (or any other weight-related metric) may unfairly penalize

Journal of Policy Analysis and Management DOI: 10.1002/pamPublished on behalf of the Association for Public Policy Analysis and Management

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individuals who are born with a genetic predisposition to obesity. Dr. Cawley impliesthat the effect of genes on body weight is probably small and that physical activitycan “eliminate” certain genetic predispositions.

Obesity often tracks in families, but it is not as predictable as other disorders, suchas Huntington’s disease. About 35 to 50 percent of the variation in body weight ina population is the result of inherited factors. Over 67 associations between BMI orobesity and changes in DNA sequencing have been reported, each of which probablyhas a small effect (Choquet & Meyre, 2011). So, we know obesity is highly herita-ble, but the mechanisms have not been worked out yet. Researchers are activelysearching for the missing heritability factors. New research tools can expand ourunderstanding of causal role of genetics (Xia, 2013).

Both Andreasen (2008) and Kilpelainen (2011) found physical activity attenuates,but does not eliminate, the risk of obesity from one specific polymorphism. Thesefindings appear consistent with many studies showing increased physical activityhaving low to modest effect on weight loss. The amount of physical activity nec-essary for significant weight loss achievement is much greater than the amountsrecommended by public health authorities (Swift, 2014). Genetic variation actuallyexplains about half the differences in daily physical activity and sedentary behavior(Hoed et al., 2013).

Regarding persons with morbid obesity being targets of EWPs, the amount ofweight a person with morbid obesity needs to lose to improve health is far in excess ofwhat an EWP can be expected to provide. In fact, most would benefit from bariatricsurgery, but this is often excluded in group benefit plans (Obesity Coverage, n.d.).

Friedman (2009) observes that an average individual will consume around a mil-lion calories a year. Yet weight remains remarkably stable. He notes

Although many believe that food intake is primarily a voluntary, conscious behavior,evidence suggests that the balance between energy intake and output is largely controlledby a powerful, unconscious biological system. This is why when motivated individualseat less and exercise more, ultimately the biological system confers a powerful drive toeat until the individual resumes their starting weight (p. 341).

Dr. Cawley sees workplaces possibly providing beneficial peer support. Alas, ev-idence is strong that workplaces are often hostile environments to overweight andobese employees. A meta-analysis confirmed discrimination in hiring, placement,compensation, promotion, and termination (Rudolph et al., 2009). A recent surveyindicated that employers are planning on increasing the incentive/penalty provi-sions of their plans to offset the coming “Cadillac Tax” on high-cost health plans,which starts in 2018. EWPs have not demonstrated that they improve ROI throughreduced health care utilization (Giardina, 2014). Clearly employers see a financialadvantage to shifting more costs to overweight and obese workers.

The Affordable Care Act was not intended to promote externalizing costs. Rather,it took a major step in the opposite direction by eliminating preexisting conditionsas a rationale to deny coverage. The extension of the amount of incentive/penaltyfor EWPs was the exception to the purposes of the ACA, not the rule.

Therefore, I remain convinced that EWPs’ benefit to employees is speculativewhile the penalty is very tangible and benefits employers by cost-shifting.

MORGAN DOWNEY, J.D. has been active in the obesity field since 1997 and is currentlyEditor and Publisher of the Downey Obesity Report, a web-based newsletter on devel-opments in obesity research and health care policy (www.downeyobesityreport.com).He can be contacted at 4421 Yuma Street, NW, Washington, DC 20016. e-mail:([email protected]).


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REFERENCES

Andreasen, C. H., Stender-Peterson, K. L., & Mogensen, M. S. (2008). Low physical activityaccentuates the effect of the FTO rs9939609 polymorphism on body fat accumulation.Diabetes, 57, 95–101.

Bluher, M. (2012). Are there still healthy obese patients? Current Opinion in EndocrinologyDiabetes and Obesity, 19, 341–346.

Choquet, H., & Meyre, D. (2011). Molecular basis of obesity: Current status and futureprospects. Current Genomics, 12, 154–168.

Downey, M. (2013). Employer wellness incentives questionable origin. The DowneyObesity Report. Retrieved April 7, 2014, from http://www.downeyobesityreport.com/2013/01/employer-wellness-incentives-questionable-origin/.

Friedman, J. M. (2009). Causes and control of excess body fat. Nature, 459, 340–342.

Giardina M. (2014). Employers consider wellness to offset Cadillac Tax: Survey. EmployeeBenefit News. Retrieved March 29, 2014, from http://ebn.benefitnews.com/news/employers-consider-wellness-to-offsets-cadillac-tax-survey-2739924-1.html.

Hoed, M. D., Brage, S., Zhao, J. H., Westgate, K., Nessa, A., Ekelund, U., Spector, T. D.,Wareham, N. J., & Loos, R. J. F. (2013). Heritability of objectively assessed daily physicalactivity and sedentary behavior. American Journal of Clinical Nutrition, 98, 1317–1325.

Kaiser Family Foundation. (2013). 2013 Employer Health Benefits Survey. Retrieved March27, 2014, from http://kff.org/report-section/2013-summary-of-findings/.

Kilpelainen, T. O., Qi, L., Brage, S., & Sharp, S. J. (2011). Physical activity attenuates theinfluence of FTO variants on obesity risk: A meta-analysis of 218,166 adults and 19,268children. PLoS Medicine, 8, e100116.

Mukhopadhyay, S., & Wendel, J. (2013). Evaluating an employee wellness program. Interna-tional Journal of Health Care Financing and Economics, 13, 173–199.

Obesity Coverage. (n.d.). Weight loss surgery insurance coverage and costs. Retrieved March27, 2014, from http://obesitycoverage.com/insurance-and-costs/.

Oliveros, E., Somers, V. K., Sochor, O., Goel, K., & Lopez-Jimenez, F. (2014). The concept ofnormal weight obesity. Progress in Cardiovascular Disease, 56, 426–433.

Rosenbaum, M., & Leibel, R. (2012). Brain reorganization following weight loss. Nestle Nu-tritional Institute Workshop Series, 73, 1–20.

Rudolph, C. W., Wells, C. L., Weller, M. D., & Baltes, B. B. (2009). A meta-analysis of empiricalstudies of weight-based bias in the workplace. Journal of Vocational Behavior, 70, 1–10.

Swift, D. A., Johannsen, N. M., Lavie, C. J., Earnest C. P., & Church, T. S. (2014). The role ofexercise and physical activity in weight loss and maintenance. Progress in CardiovascularDisease, 56, 441–447.

Xia, Q., & Grant, S. F. A. (2013). The genetics of human obesity. Annals of the New YorkAcademy of Sciences, 1281, 178–190.


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RESPONSE TO DR. CAWLEY