On Capitol Hill, lawmakers seem eager to encourage employers to create and expand programs that tie a portion of workers' health insurance premiums to their willingness to change unhealthy behaviors. But there's growing concern that some of those programs represent a new way to discriminate against those in less than perfect health.
By a vote of 18-4, the Senate Finance Committee added to its health overhaul bill an amendment offered by Sens. John Ensign (R-NV) and Tom Carper (D-DE) that would expand existing rules that let workplace "wellness" programs pay bonuses in the way of reduced premiums to workers to lose weight, quit smoking, control their blood pressure or practice other healthy behaviors.
Current rules allow premiums to vary by up to 20 percent of a worker's total health insurance premium. Under the amendment adopted by the committee, that could rise to as much as 50 percent.
"We know that the more we pay for things, the more we're going to get. And so we need basically to pay for healthy behaviors," Ensign said.
But the potential change has alarmed groups like the American Cancer Society, American Heart Association and American Diabetes Association. They say that lowering premiums for some people inevitably means raising them for others, and that those others are usually sicker people.
"The whole point of health care reform is to make sure that everyone gets insurance," says Dick Woodruff, senior director of federal relations at the American Cancer Society-Cancer Action Network. "And if people have to pay more because they're unhealthy, that's a barrier. It defeats the whole purpose."
Woodruff says groups like his are all for encouraging workplace wellness programs — but not by using health insurance to do it. "Companies, if they want to have healthy employees, they should offer gym memberships or healthy meals in the cafeteria or opportunities to exercise," he says.
But tying wellness to health insurance "is a sort of a backdoor way of underwriting for people who are overweight or who have high cholesterol or they smoke," he says, "and a way of getting them out of the system. It allows insurers and employers to cherry-pick."
Karen Pollitz, a Georgetown University research professor who studies the insurance industry, says some existing wellness programs already clearly separate the sick from the healthy.
One plan, for example, starts everyone out with a $2,500 annual deductible. Then it offers $500 discounts from that total to those who can pass tests related to smoking, weight, cholesterol and blood pressure.
"So if you can pass all of the tests, you're back to having a $500 deductible, which is kind of standard for employer plans today," she says. "If you can't, if you're unhealthy, you have a $2,500 deductible."
She says that can produce two possible results: "One is that the unhealthy employees just have to pay $2,000 more of the cost of their care every year. But second, some of those employees may say, 'Forget it, I'm going elsewhere. I want to get covered under my spouse's plan.' "
Both options save the employer and the insurer money, but don't necessarily improve anyone's health.
The Cancer Society's Woodruff says the groups have another worry about employer wellness programs: Do workers really want their employers to have so much of their personal information?
"I think it's incredibly intrusive for a person to go to work and have to undergo, for instance, a cheek swab. And the results of that information get filed away somewhere. You don't know what happens to that information," he says, either when you're working for that employer or after you leave the job.
Backers of the wellness language, however, insist that the emerging health bills should include patients among those asked to make sacrifices.
"If you look at [the bill], we have not done a whole heck of a lot with respect to saying to individuals that we have some responsibility here, too, to do a better job of taking care of ourselves," Carper said.
It's a debate that's likely to continue when the bill reaches the Senate floor.