post by Bill Gardner
Yesterday, I summarized a meta-analysis that suggested that corporate wellness programs provide a positive return on investment by controlling employee's health care costs. Today I want to look at whether these programs are coercive.
Ezra Klein raised this concern in his post on the successful Cleveland Clinic employee wellness program:
[C]onsider what [changing health behaviors] actually entails: Changing habits. Breaking addictions. Getting people to the gym. Who wants to hear about any of that from their employer? The clinic, however, didn’t give employees a choice. “First thing we said was we had to make our institution toxin free,” [Cleveland Clinic Chief Wellness Officer] Roizen said. “The biggest toxin we have in the U.S. is tobacco. So we began offering free tobacco-cessation programs to our employees. Then we banned smoking on campus. You can’t even smoke in the parking lot in your car. The first offense you get a warning, and the second you get fired. We fired two high- profile physicians who refused to quit. Then they knew we were serious.”
Klein (see also here and here) noted that
Whether [the Cleveland Clinic's] success is a model for American health care or a preview of a dystopian surveillance state is an open question.
Let's step back, though, and ask what 'coercive' really means. Suppose someone confronts you in the dark with a pistol and says, "Your money or your life." This is coercion. Now suppose you are diabetic and need insulin, but your pharmacist won't give it to you unless you pay for it. In both cases, you are in life-threatening circumstances, unless you give someone money. But in most cases we feel that even though the pharmacist may be pressuring the diabetic, he isn't coercing her. The reason is that we view a threat with a gun as an illegitimate form of pressure, whereas barring dire emergency we believe that pharmacists have the same right to require payment as any other merchant. We distinguish coercive situations from legitimate pressures based on our moral judgments.
So is what the Cleveland Clinic does coercive? Americans have complex views about what norms employers can legitimately require you to conform to, but in general your employer has wide scope to regulate your behavior. Your boss can require you to be punctual, if that is essential to the functioning of the business. But you can't be discriminated against on the basis of your religion. Your employer can, however, require you to meet a dress code -- unless it's a matter of dress or grooming required by your religion. And so forth. How do we feel about pressure to conform to norms of healthy behavior? My sense is that as people come to understand that unhealthy behavior is a significant business cost, they will increasingly accept employers' monitoring and enforcement of norms about healthy behavior.
But although I believe Americans would accept Cleveland Clinic style carrots and sticks as part of voluntary employment contracts, they would not accept them if they were imposed by the government. Citizenship isn't voluntary in the way that employment is.
Do you think the argument about coercion yes/no changes when the target population moves from an employed population to a Medicare or Medicaid population? Insurance incentives will increasingly require changes in human behavior on the part of patients and families and be strong enough to make providers move on those issues.
Posted by: Kelly Kelleher | 10/21/2011 at 06:33 AM
Great question, and I do think the argument changes. See the next post!
Posted by: Bill Gardner | 10/21/2011 at 07:09 AM
I haven't thought enough about these issues, so I'm glad you're raising them. I do wonder if the largely involuntary nature of citizenship really does the work you're asking of it here. In the employment context, the employer says, "This is the new policy; if you don't like it, work elsewhere." In the context of government policy, you suggest the government will be saying, "This is the new policy for all citizens; if you don't like it, leave the country." And that indeed does sound draconian. But there is an alternative thing the government could say, which is: "This is the new policy for all citizens; if you don't like it, you must pay some opt-out penalty (or maybe pay for some of your own Medicare expenses)." This last option is sufficiently non-draconian that it now seems much closer to what the employer says when he says "Ok, then get a job elsewhere."
I think this suggests that if we have problems with the government doing it, we're either confused about what the government really would be demanding of us, or else we're responding to these demands differently than we might respond to them if the employer made them. Perhaps there is some other reason to be skeptical of governmental policy; maybe this comment suggests we should be looking for it.
Posted by: Paul Kelleher | 10/22/2011 at 01:04 PM