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Special Report on Health Care BenefitsPound-Foolish

September 10, 2009
Before he was a thin man, Mark Blei, a soft-spoken New Yorker with 20 years of sales experience, rolled with the fat jokes and perceived slights.

In 2005, weight-loss surgery that was paid for by his employer, a direct marketing firm, helped him shed most of the nearly 400 pounds that draped his 6-foot-tall frame. It dawned on him then, as he reached 145 pounds within a year of his surgery, how much his weight had made him a pariah.

“Imagine being a black man in the 1950s, applying for a six-figure job,” says Blei, 41. “And then one day you wake up and you are a rich white guy who happens to look like Brad Pitt. That’s what it was like.”

Co-workers who once were embarrassed to be with him in public adored him. Secretaries who once were rude now flirted. He looked great but felt terrible.

“It’s a professional environment. You can’t say, ‘I’m just as good of a person now than when I had 150 more pounds on me,’ ” Blei says. “A friend suggested I get another job, otherwise I’d be angry knowing how shallow people were.”

Soon after his surgery, Blei quit his job and moved to Toronto.

Blei’s experience, and those of other obese workers, underscores just how emotionally fraught weight loss can be for employees. Obesity is at once an intensely personal yet very public condition. It’s also one that more employers are delving into, through weight-loss and wellness programs, as they see health care costs for obesity-related conditions rise.

Yet obese workers and obesity experts say that employers’ activism often occurs with little understanding of what it’s like to be an obese person in the workplace. They don’t grasp the prejudice these workers face and the impact their experiences may have on their ability to lose weight or lead healthier lives. Weight-related health care and workplace policy can end up punishing workers for their obesity rather than helping them overcome a condition that has been linked to—though is not always synonymous with—higher health care costs.

“I don’t think shunning or isolating people who are obese has helped reverse the march of obesity in this country,” says Christine Ferguson, a professor of health policy at George Washington University.

Obesity explosion
As most employers know, Americans are getting fat fast. In 1995, 16 percent of the population was obese; last year, about 27 percent of American adults were obese—nearly a 70 percent increase that translates to 72 million obese Americans. Also, two-thirds of Americans are overweight, according to data from the Centers for Disease Control and Prevention.

A 6-foot-tall man like Blei is considered to be overweight if his body mass index—the ratio of a person’s weight to height—is 25 or higher. That means he would have to weigh more than 185 pounds. Blei would be considered obese at more than 221 pounds, which translates into a body mass index of around 30.

A person who is 100 pounds over normal weight and who has a BMI of greater than 40 is considered morbidly obese. Body mass index is often used to assess an unhealthy weight but should be seen only as a rough guide, since most doctors would not consider a 6-foot-tall athlete weighing 185 pounds to be unhealthy, even if he is technically overweight.

In the past, employers didn’t concern themselves with the challenges faced by obese workers. But once it became clear that weight was costing employers money, that changed.

As the number of obese employees increased, so too did the costs associated with treating illnesses related to obesity—diabetes, heart disease, several types of cancer and skeletal disorders. Moderately obese employees tend to cost employers $670 more per year than workers who are normal weight; severely obese employees cost $2,441 more per year, according to a 2007 research brief by Thomson Healthcare.

Some employers have responded by taking a more active role in the health of employees, using disease management programs, wellness programs and, in some cases, financial incentives and penalties to get people to lose weight.

Incentives vs. penalties
The prevalence of obesity has brought more scrutiny to obese employees and potential hires who are significantly overweight.

Renzie L. Richardson, a former HR director at a telecommunications company in Atlanta who is now a health and wellness consultant, says a prospective employee’s weight—especially when at an obviously unhealthy level—was an issue “in the back of my mind” during the hiring process.

“I had to contain costs in terms of our health plan. … If I felt this person would be a high-risk hire, I wouldn’t move forward” with the hire, she says.

Sometimes, obese workers say, it seems these attitudes shape health care benefit policies. For example, in August 2008 the State Employees’ Insurance Board of Alabama, where 45 percent of state workers are obese, approved a plan to charge state workers more for health insurance premiums if they don’t take steps to lose weight. Other states, most notably South Carolina, have contemplated similar measures.

Once employees at Scotts Miracle-Gro in Marysville, Ohio, have been identified as having health problems such as being overweight or obese, they must pay $75 more a month for health insurance if they do not meet with a health coach. The company says the threat of penalties translates into a 90 percent participation rate in its wellness programs.

Like Scotts, other employers are using a mix of penalties and incentives to get obese workers to live healthier lifestyles, thanks in part to revised rules under the Health Insurance Portability and Accountability Act. The new HIPAA rules, clarifying what is permissible, say employers can use incentives equal to as much as 20 percent of the cost of health insurance to encourage workers to meet health targets, such as a lower BMI, as long as an alternative target is available for those workers who cannot reasonably be expected to reach such a goal. Workers who meet these targets pay less for health insurance; workers who don’t pay more.

Political pressure and public sentiment, though, seem to play a role in how far some employers are willing to go to help employees lose weight.

Earlier this year, commissioners in Collin County, a suburb of Dallas, voted to stop paying for employees’ weight-loss surgeries. Canceling the program, which has cost the government $3 million, was simply a matter of trimming its budget during a recession, said Commissioner Joe Jaynes.

But body politics also played a role. Despite recent evidence that some people who undergo weight-loss surgery experience complete remission of diabetes, many view the surgery as something akin to a nose job.

“People think it’s cosmetic,” Jaynes says. “With the cost, we were getting to the point where we had to cut it, and the political misperceptions sped that up.”

Recent research has shown that weight-loss surgery can be cost-effective for employers that have low turnover. An article last year in the American Journal of Managed Care showed that employers could recoup the cost of weight-loss surgery—which ranges from $15,000 to $30,000— within as little as two years. Ferguson says Collin County’s decision to end its weight-surgery benefit reflected a sense that surgery would reward people for being overweight.

“Are people who are obese deserving of treatment? That is the issue,” Ferguson says. “In this country, we are still in a position where we don’t think they are deserving. People think it’s somebody’s fault and that treating it would reward the person.”

That sentiment ignores the fact that obesity is the result of a complex web of choice and circumstance.

Blei, for example, turned to food for comfort but also came from an obese family. By the time he was 15, his dad weighed 350 pounds, he says. Melissa Davis, 26, a college graduate who weighs 270 pounds and has struggled to find a long-term position, grew up with parents who emigrated from Belize in a household where wasting food was considered an insult. Andrea Mucci Bjorklund, 35, doubled her former weight of 130 pounds amid the pressures of working while attending night school.

Yet obese workers are quick to point out that thin people can be unhealthy too. Less attention is paid to them because their appearance can mask underlying problems that nonetheless can register on the health care ledger. According to Thomson Healthcare, underweight employees cost $377 per year more than workers of normal weight.

“A thin person could be a couch potato, but you just don’t know it because they’re thin,” Bjorklund says.

Realistic goals
One problem, obese workers say, is that incentives and penalties miss the obvious: Most obese people already want to lose weight. They simply can’t do it, or feel as if the standard of health is beyond their reach.

Davis tried all sorts of diets to lose weight, including one that allowed her to eat only between noon and 6 p.m. each day. Practically starving herself, she lost 25 pounds in one month. She also ended up in the hospital.

Benefits experts suggest employers set more moderate goals, such as trying to lose 10 percent of one’s body weight, rather than achieving a “normal” body mass index.

Employees and employers support programs that help people lose weight. But the programs are much more effective when companies use positive incentives, says Jon Gabel, who recently analyzed surveys of employer weight management programs.

“It seems like obese employees are more supportive of programs than anyone else,” he says. But, he adds, the stigma that obese people are less intelligent and less capable is “an overwhelming problem” that can make it harder for employers to help obese workers.

Ferguson says employers interested in helping employees lose weight would do well to recognize the harm that can come from stigma and discrimination.

“It’s very clear from the data that penalties and stigma have not in any way helped achieve a reversal in the obesity epidemic,” she says.

Obese workers are quick to say this stigma is often subtle, though for employees like Blei, who lived life as an obese man before losing weight, the difference in how obese workers are treated can feel as real as the difference between night and day. Back on the job search after his weight-loss surgery, Blei interviewed with a manager who had once turned him down for a sales position years before.

“Everything seemed familiar. We sat down, I answered his questions the exact same way I did the first time,” Blei says. “He offered me the job on the spot, right there.”

Workforce Management, August 17, 2009, p. 22-27 -- Subscribe Now!