Charging disabled people more for health care is illegal. But what about ... charging non-disabled people less?
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Charging disabled people more for health care is illegal. But what about ... charging non-disabled people less?
Support us:
Links!
[Maintenance Phase theme]
Aubrey: Oh, fuck, I got to have a catchphrase, huh?
Michael: Oh, first time doing this.
Aubrey: It's been a minute.
Michael: [laughs]
Aubrey: [chuckles] Hi, everybody, and welcome to Maintenance Phase, the podcast that won't charge you extra, if you're fat or disabled to have a job?
Michael: [laughs] That was a very direct one. I know your thoughts on this matter at this time.
Aubrey: This is one where I am not coming in fresh, and it's one where I have strong feelings already, and I am looking forward to having those feelings fed.
Michael: I am Michael Hobbes.
Aubrey: I'm Aubrey Gordon. If you would like to support the show, you can do that at patreon.com/maintenancephase or you can buy t-shirts, mugs, tote bags, masks, all kinds of stuff at TeePublic, both of those are linked for you handy dandy in the show notes. You can also listen to Mike's new show, If Books Could Kill, wherever you get podcast and you can pre-order my new book, “You Just Need to Lose Weight”: And 19 Other Myths About Fat People, both of those are also linked for you in the show notes. And, Michael, today, we're talking about workplace wellness programs, yes?
Michael: I interrupted your rant to make you talk about logistics and now, you can go back to it.
Aubrey: [laughs] I was like, "Oh, right, housekeeping."
Michael: Yeah.
Aubrey: "Bathrooms are over here."
Michael: Yeah.
Aubrey: "Put your pronouns on your name tag. Let's roll."
Michael: [laughs] What are your thoughts on workplace wellness, Aubrey?
Aubrey: So many, many workplace wellness programs, not all of them, but many of them will provide folks with either bonuses or lower healthcare premiums based on their participation in or higher marks on-
Michael: Yes.
Aubrey: -specific health and wellness metrics. I was talking to a friend of mine who works in a municipal government, one of her people who works in her department came to her and was like, "Hey, I did our workplace wellness thing. I have an eating disorder. Starting the day with getting weighed was not my favorite."
Michael: Ooh, yeah, doing it at work, getting weighed at work. Yeah.
Aubrey: In front of your co-workers in a non-HIPAA setting.
Michael: Yeah.
Aubrey: I think it's worth questioning why on earth this is the job of an employer to do.
Michael: Oh, my God, you're spoiling something that I was saving for the last five minutes of this episode, [Aubrey laughs] but, yeah.
Aubrey: It just feels like a real boundaryless mess of a system. It's a real boundaryless mess of a system that has just permeated almost every major workplace that I'm aware of.
Michael: Dude, 92% of employers in the United States have some form of workplace wellness program.
Aubrey: Shut the fuck up. Are you kidding me?
Michael: It's somewhere between like a $4 billion and a $10 billion industry.
Aubrey: Holy shit.
Michael: What is wild to me is that workplace wellness programs have been around for decades. We will get into it. And there is no fixed definition of what workplace wellness actually means.
Aubrey: Oh, get fucked. So, this is a like natural foods thing?
Michael: Yeah, exactly. So, a lot of the articles that you read, some employers say like, "Yes, we have a workplace wellness program." What they mean by that is that there's a poster in the break room being like eat five fruits and vegetables.
Aubrey: Uh-huh.
Michael: Then other employers have these really comprehensive, you get this incentive and there's this BMI bonus and there's this discount on your health insurance, like really, really hardcore programs. But they're both labelled as workplace wellness.
Aubrey: Yeah. The two that I remember most clearly and feel the most galling examples to me, one is the Whole Foods BMI discount, which was you would get a greater employee discount, if you had a lower BMI.
Michael: I believe it was visible on the card too. Other employees could actually-- I think it would come up at the register to be like, "Oh, this person gets 15% off."
Aubrey: The fucking barf.
Michael: Yeah, it's really barf.
Aubrey: The other was a brand of chocolate that I have otherwise enjoyed in my life. Tony's Chocolonely had a BMI bonus, where they would just straight up pay people more money, if you had a lower BMI. And they got enough blowback on it that they changed it to be a maintain your BMI bonus. So, if your weight stayed the same, then you would get that bonus, which is also still garbage.
Michael: It's also discriminates against people like me who were trying to get huge, bro, you know?
Aubrey: What about the dudes who are going for gains, bro?
Michael: I know. What about the skinny shaming throughout our society?
Aubrey: Okay.
Michael: What about that? No one wants to talk about that.
Aubrey: Listen. Good. Yeah, you nailed it.
Michael: I want to start out by just trying to define what this is, because especially for people that do not live in the United States, this is completely fucking baffling.
Aubrey: Yeah.
Michael: Even though they do have workplace wellness programs, even in other countries and other countries where they have more socialized medicine, this is a cancer that has taken over the employer-employee relationship basically everywhere, which is quite shocking. But it's much more prevalent in the United States, because roughly 60% of the population in the United States gets their health insurance through an employer, either your own employer or your spouse's employer. So, this is most Americans.
Aubrey: Yeah.
Michael: The closest thing to a definition of workplace wellness that I could find is any program carried out by an employer that promotes healthy behaviors. In some of the articles about the history of workplace wellness and the components of workplace wellness, they'll include stuff like occupational health and safety programs which like, "No, a lot of that's legal compliance anyway." Sometimes, you see histories of this that will say like, "The 40 hours work week is a workplace wellness program."
Aubrey: Oh, Christ. Are you kidding me?
Michael: No. People who were doing that before it was a legal compliance issue were mostly doing that to get more productivity out of their workers. So, workplace wellness has to be something above and beyond like what you have to do as an employer or just something you're only doing explicitly to get more productivity out of your workers. So, that's what we're talking about is like this extra stuff.
Aubrey: We're also not talking about you have a boss who won't shut up about their diet or you have a co-worker-
Michael: Exactly.
Aubrey: -who's talking about what everyone else is eating. We're talking about formal, institutionalized workplace wide programs that either strongly suggest, or incentivize, or mandate employee participation.
Michael: Yes. When we talk about workplace wellness programs, it's a mix of good, neutral, and extremely bad things.
Aubrey: Interesting.
Michael: We put out a call toward the beginning of the research for this episode of like, "Tell us your workplace wellness stories," back when I thought this was going to be like a fun freewheeling episode. I was wrong.
Aubrey: [laughs] You thought you were going to do something laid back and you found out-
Michael: I know.
Aubrey: -a real rabbit hole.
Michael: I was like, "Oh, it was going to be a cute one." No, it's not cute.
Aubrey: [laughs]
Michael: We got 700 emails. So, we are going to do a bonus episode where we go further into like what workplace wellness programs actually entail right now and they're utterly fucking deranged stories that we heard from our listeners. But there's a couple of broad categories that we found when we started getting emails and when I was reading up on this. So, arguably, there are some workplace wellness programs that are good. A lot of employers will provide free flu shots.
Aubrey: Oh, great.
Michael: I don't love that being provided at an employer, but also, more people getting vaccinated against the flu is a good thing.
Aubrey: I don't know, it continues this insidious thing of like, "Your employer is kind of your healthcare provider in some way."
Michael: Exactly.
Aubrey: You know what I mean? So, it's like blurring some lines. Also, I think the number one reason certainly that people I know don't get a flu shot is just the inconvenience.
Michael: Right. We also heard from listeners whose employers started giving them more time off or kind of personal days. One listener said that her workplace gives you Friday afternoons off, like no questions asked, if you just need to take some time for yourself. So, cool.
Aubrey: That's great.
Michael: The last example of a good one that I have is a lot of employers also try to have healthier food in the cafeteria, having an option for people that has, I don't know, more vegetables in it or whatever. That seems fine to me. Great.
Aubrey: Sure.
Michael: I would say probably the largest category is programs that are really dumb but kind of benign. So, a lot of employers offer subsidized gym memberships.
Aubrey: Oh.
Michael: It's the kind of thing that, if my employer didn't offer that, I wouldn't ask for it, but also sure.
Aubrey: Yeah, I would also accept an employee discount for a Netflix membership. You know what I mean?
Michael: Exactly. Like whatever.
Aubrey: Sure, you want to give me discounts on stuff? Sure, sure, sure, sure, sure.
Michael: Yeah. Some people said that their workplace will bring in people to do yoga sessions during work voluntarily. One person said their work brought in a masseuse once a month to give free massages to employees, but they worked at a cafe as a barista and there was no room in the back, so they would just get a massage in the cafe in front of all the customers. [laughs]
Aubrey: Shut the fuck up. [laughs]
Michael: I guess, the customers would be like, "I'm next." She's like, "No."
Aubrey: Yeah, I'm sure.
Michael: I don't think it's really doing much for your health particularly, but also just like, yeah, time that you're getting paid and you get a free massage at work, whatever, right?
Aubrey: Great.
Michael: Then, A lot of employers do things where they'll have a bowl of fruit at the reception desk, they'll send out a weekly health tip to employees. They seem pretty dumb to me, but also, they seem harmless. You can say that like, "Okay, they're entrenching this paradigm and we'll get into it." But also, the amount of just dumb shit that your employer does and you have to deal with at work. It's like having a couple bananas at the reception desk seems fairly low on that ladder to me.
Aubrey: I think, listen, it's hard for me to talk about workplace wellness programs without grading on a real sharp curve.
Michael: Yeah.
Aubrey: Of course, on its face, a lot of these are things that I don't think really have an appropriate place in the workplace. If we had better healthcare systems, none of this would be in the workplace to begin with-
Michael: Exactly.
Aubrey: -and we would think of this as a weird thing.
Michael: Well, this brings us to the bad stuff.
Aubrey: Yeah, tell me.
Michael: The main one is, yes, these financial incentives that essentially, if you meet certain health "parameters," you pay less for your insurance premiums. Oftentimes, this is done in a fairly public way. So, one email that we got from listeners said, "My last job would give you roughly $200, if you lost a specific amount of weight over the course of a year. You would go into a practitioner in the office to do a full health screening and whatever they determine is an appropriate amount of weight you should lose is your health marker goal for the next year. You get money when you join the program, and every year after, if you continue to do the health screenings and lose weight. It's gross and I hate it."
Aubrey: Yeah.
Michael: So, it's that sort of stuff where we're bringing in extremely personal health information and this whole fucking weight paradigm basically into your relationship with your employer. In some cases, you're like direct boss. Some people described having these wellness plans that they put together with their boss and it covers things like, "Oh, you have to go to acupuncture, chiropractor, whatever, once a week." And you'll actually get a discussion with your boss if you miss one of your wellness appointments.
Aubrey: Jesus fucking Christ.
Michael: Wildly inappropriate.
Aubrey: The boundarylessness of all of this is-
Michael: Yeah, exactly.
Aubrey: -fucking staggering. Think about how much you hate to answer to your fucking mom about your body-
Michael: I know.
Aubrey: -or your health and wellness shit at the holidays. Now, imagine that's your boss and it's every time you talk to your boss, that's a conversation that's on the table.
Michael: I know. I'm trying to think of the people I want involved in my relationship with my body the least,-
Aubrey: Yeah.
Michael: -like my boss and my employer. [laughs]
Aubrey: Yeah, exactly.
Michael: Another really common one is Fitbit challenges or like Fitbit metrics. So, the idea is, if you get 10,000 steps, you get a discount off of your health insurance, which on the surface at first glance, I can see how that sounds fun. "We're all going to try to move more," or whatever. First of all, it's effectively a form of surveillance. It's your activities outside of work, now playing into the way that you're assessed at work. And also, a huge number of people cannot participate in these challenges due to disability issues, due to having a second job, due to childcare responsibilities, and all of this requires those people to disclose this to their boss.
Aubrey: Right.
Michael: You're basically creating something that's like, "Oh, it's going to be fun. We're all going to walk together." But you're putting people into a situation where they either have to walk 10,000 steps a day outside of work or they have to tell you why they can't. As you can imagine, this also drives a lot of really fat phobic and condescending bullshit at work. So, people sent in photos of various posters that their bosses put up at work. One of them had a sign on the elevators that said, "Push yourself, not the button. Take the stairs when possible."
Aubrey: Which is also, a specific favorite of yours is the "take the stairs" bullshit.
Michael: Take the stairs, dude.
Aubrey: The idea that, if fat people took the stairs up two flights of stairs or whatever every day that suddenly we would not be fat people anymore.
Michael: Exactly.
Aubrey: Get the fuck out of here.
Michael: It also just makes you super conscious of if you're a fat person at work of your fatness like other people, you're all waiting for the elevator together.
Aubrey: Right.
Michael: It's like, "Oh, you guys, you should be taken down the stairs." All this does is drive bullying and drive a culture at work of everyone assessing each other's bodies and health behaviors.
Aubrey: Abso-fucking-lutely. Listen, if people get it into their head that it is part of everyone's job description to look healthy in a way that is legible to mostly thin, mostly non-disabled people, you are then being enlisted in a project of making other people feel like shit.
Michael: Do you want to hear the worst surveillance category of workplace wellness bullshit that we got?
Aubrey: Okay.
Michael: This one's fucking unbelievable. "I worked for a large organization who had a third-party company who ran health challenges on their behalf. It was operated through an online portal where people could accumulate points for doing things like getting their annual health check-up, et cetera. Pretty benign. Until they introduced a forum where you could post photos of co-workers you caught being unhealthy and tag them in it."
Aubrey: Shut the fuck up.
Michael: That's right. They built in a public shaming feature with no way for the person you took a photo of to opt out.
Aubrey: Okay.
Michael: Guys, guys. [laughs]
Aubrey: So, I am going to start throwing up crying and punching.
Michael: I need the address of this building, so that I can burn it down.
Aubrey: That's turning everywhere into fucking 8chan.
Michael: So, we're going to circle back to the worst workplace wellness and the myriad reasons why it's bad, but we have to go through the history.
Aubrey: Ooh.
Michael: Basically, as long as we've had workplaces, we've had weird wellness efforts by bosses imposing them on their employees.
Aubrey: Wait, really?
Michael: Yeah. So, Milton Hershey, the guy like the Hershey's Chocolate guy had a leisure park connected to the chocolate factory where he expected employees to go and do calisthenics during the day.
Aubrey: Pilates before Pilates, calisthenics. Yeah.
Michael: The National Cash Register Company, which was like hot shit in the late 1800s and early 1900s offered horseback rides to employees before and after work.
Aubrey: That sounds good to me.
Michael: That's one of the good ones.
Aubrey: I go on a little horse ride.
Michael: But then, I don't know, if these actually count as workplace wellness programs, because they're basically companies that have too much profit and founders that have these eugenics adjacent ideas about hiring the right kinds of workers.
Aubrey: Uh-huh.
Michael: These programs eventually expand to things like helping workers quit smoking, helping workers quit drinking. But I'm not sure those count either, because they're pretty straightforwardly productivity measures. The idea is that, if somebody's drinking, they're probably showing up late. And with smokers, you don't want people taking smoke breaks.
Aubrey: Yeah.
Michael: Also, it's pretty isolated. It's really only the largest and most profitable companies that are really doing this in the first half of the 20th century.
Aubrey: Right.
Michael: So, the first explosion of these programs happens just after World War II with the rise of Employer-Sponsored Health Insurance. Before World War II, only 10% of the US population had health insurance of any kind. And during World War II, firms were prohibited from offering higher wages to employees, because everything was controlled by the government to get wartime stuff out. So, employers started offering health benefits as basically a way of attracting workers, because we can't pay you more, but we can get you free health insurance. Once all of this manufacturing sector stuff started to get entrenched, it then became something that unions started asking for. Health insurance benefits became something that was a mainstay of collective bargaining agreements.
In the late 1940s, the government also recognized them and made them tax free. So, the government, the employers, and the employees, all wanted health benefits to come through employers.
Aubrey: That's fascinating and feels like continued adaptation to, we're going to let capitalism run our healthcare system.
Michael: Oh, yeah.
Aubrey: You start bargaining for this in employer contracts when you don't see any path to any other way to get healthcare and health insurance.
Michael: Right. Profits and health, what could go wrong?
Aubrey: Yeah. Boo.
Michael: So, the real ramp up to modern workplace wellness programs begins in the 1970s, when two interlinked things happen. The first is that the cost of healthcare explodes. In 1960, companies were spending about 25% of their payroll on health benefits. And by 1980, they were spending 41%.
Aubrey: Wow.
Michael: I read a bunch of papers about why healthcare spending exploded in the 70s and 80s. It seems to be a combination of the population getting older, much more access to healthcare services. It was expanding to rural areas. Also, the consolidation of healthcare services, they're basically starting to merge and starting to realize that you can charge literally anything for healthcare, which is like the situation that we're in now. But the point is, Americans started spending way more money on healthcare and employers were starting to get really nervous in the 70s and 80s like, "Hmm, this is becoming a problem."
The second factor that contributed to this was the invention of wellness. So, we are going to watch a clip from 60 minutes-
Aubrey: [gasps]
Michael: -from 1879.
Aubrey: I think I have seen this clip.
Michael: Is it the Dan Rather one?
Aubrey: Yes. Where he's like, "What is wellness?"
Michael: Yes. Dude, it's such a fascinating artifact. Oh, my God.
Aubrey: Mike, it's so fucking good. I love it so much.
Michael: It's great. They're like, they call it "self-care." [laughs]
Aubrey: It's incredible. Okay.
Michael: Okay, here it is.
[video plays]
Dan: It's a movement that is catching on all over the country among doctors, nurses, and others concerned with medical care. Wellness is really the ultimate in something called self-care, in which patients are taught to diagnose common illnesses and where possible to treat themselves. More than that, it is a positive approach to health, what one doctor calls recognizing that health is not simply the absence of disease."
Teresa: I had been in and out of the Cleveland clinic. I had seen numerous specialists in various areas, and I just was so tired and so fed up being in so much pain that I'd spent. I would give you a ballpark figure of about $35,000 over the last nine years in medical care.
Dan: Traditional medical care.
Teresa: Yes. And had achieved nothing.
Travis: 152, 153.
Dan: Julio Esposti joined self-care for the same reasons. He's an executive with a major West Coast firm. For years, he suffered from constant headaches and physical pain, which doctors told him it was due to stress in his work. But any test or x-ray doctors administered to Julio proved negative. Like Teresa, Julio says, he didn't find relief until he entered a program called Wellness. Now, he's what you're into a substitute practice of medicine.
Travis: No, absolutely not. It is an adjunct to and quite different from the practice of medicine. We don't treat diagnose or prescribe. Our role is to help the person discover why they're sick.
Dan: Travis does this by looking at a person's whole lifestyle, their diet, work habits, and physical activities. What solved Julio's illness problems was biofeedback.
Travis: As the tone gets lower, you are warming and you just raised your hand temperature one degree.
Dan: Biofeedback, basically is an electronic device used to measure the amount of tension or stress in a person's body. After several sessions, Julio learned not only how to relieve his pain, but also how to handle stressful situations at work.
Aubrey: Mike, when did you join self-care?
Michael: [laughs] I started caring for myself.
Aubrey: This video has the tone of my dad repeating back to my nephew what my nephew has just told him about Pokémon evolutions.
Michael: [laughs]
Aubrey: All right, so Charmander becomes Charizard.
Michael: [laughs]
Aubrey: Uncertain, but emotionally invested like, "Here for you, but not sure about all this," you know?
Michael: Also, how I conceive of heterosexual intercourse.
Aubrey: [laughs]
Michael: This seems important, but I don't know how it works.
Aubrey: It's really fascinating to me that part of the reason that this weird, shitty economy of stuff exists is that it is accounting for medical institutions not being responsive or feeling responsive in a way that patients can wrap their arms around and feel cared for.
Michael: I also love that it's this perfect distillation of where we are with wellness now, where it starts with a good concept of like, "Health is obviously something more than just like the absence of disease. You want to feel good as a person. And also, here's this quack shit that's going to measure the 'tension in your body,' and it has a bio in the name, so you think it's scientific." [laughs]
Aubrey: Boy oh boy oh boy.
Michael: This shift is something that we've talked about on the show before and I think we're going to return to a million more times that you had this shift in the understanding of public health. Throughout the first half of the 1900s, you had the eradication of polio, you had mass vaccinations, after World War II, you get penicillin. What we thought of as disease wasn't infectious disease anymore. It wasn't like you drank some tainted water and you got sick, and now we need to make sure the water isn't tainted. It became much more about these lifestyle factors. This was also the time when we start getting the Framingham study and saturated fat causes heart attacks. We also get this sense that what you are doing on a day-to-day level affects how healthy you are. This really becomes the dominant paradigm of health.
Aubrey: Yeah, it's a really fascinating thing, because I think wellness as a concept is one that tends to thrive on the left and it is predicated on an extremely conservative bootstraps kind of narrative, which is both like, "You can't really trust these institutions, but also what you need to do is get yourself together and you need to find the right practices for you. If you did, then you wouldn't be sick or you wouldn't be blah, blah." It is extraordinarily ruthless kind of logic that underpins a lot of this.
Michael: Well, I think a lot of the precepts of it are true. Heart disease and cancer are the number one and number two killers of Americans. Obviously, [chuckles] we should be taking those things seriously. Of course, our lifestyles affect our health. There is truth at the heart of this, but I think the adoption of this and especially, the take up of this by industry ends up smuggling in what the researchers call the lifestyle risk paradigm.
Aubrey: Yeah.
Michael: The fact that your lifestyle affects your risk for disease is pretty unobjectionable, but eventually, it became that your lifestyle is the only thing that affects your risk for disease. We then start getting the reverse understanding, which is, well, then everybody who's sick must have done something to deserve it.
Aubrey: I think the context here is really important, which is then, as now, we live in a world that has really, really taught us to judge and brush aside, and think less of fat people and disabled people, right?
Michael: Right.
Aubrey: If you hear a health and wellness message that feels really good to you, it's worth unpacking why it feels really good to you and what it allows you to believe about yourself and the world and your place in it, right?
Michael: Right. Well, also, this stuff almost immediately gets taken up by corporations in various ways.
Aubrey: Yeah, for sure.
Michael: In bullshit skincare marketing, but also behind the scenes. At the same time, we have this explosion in healthcare costs and we have this galloping understanding of health as due to lifestyle factors. And so, corporations look at these two things together and they say, "Well, the way that we can bring our healthcare costs down is by changing the lifestyles of our employees." So, I'm going to send you an excerpt of a really insightful article about this that was published in 1988.
Aubrey: It's amazing to me how often I dig into a topic on this show to be like, "Ooh, this is really ripe for debunking." And then you find the journal articles that have debunked the shit out of it and they're like 40 to 70 years old.
Michael: I know.
Aubrey: You're like, "Oh, man, we've known this whole time."
Michael: I know. 10 minutes after it happened, somebody's like, "This seems bad" and then we have to make a podcast 40 years later.
Aubrey: [laughs]
Michael: Here's this.
Aubrey: Okay. "In the 1980s, American industry has adopted cost containment as a key to corporate health policy. The incentives are substantial, for if companies can reduce their medical insurance and disability claims, they may be able to lower their health costs and potentially reduce their insurance premiums. Corporations and their insurers have developed multipronged plans to control health costs, including more cost sharing with employees, second opinions for many elective surgical procedures, incentives for outpatient surgery, encouragement of alternative health providers, and worksite health promotion. Thus, worksite wellness programs with their goal of keeping employees healthy and reducing medical care utilization are a part of this cost containment strategy." It's just about money.
Michael: Very openly, corporate executives were saying this at the time.
Aubrey: It's really amazing to me what a fucking hot potato healthcare costs are.
Michael: I know.
Aubrey: Everyone's doing the thing where you like put your finger on your nose and go nod it.
Michael: Yeah.
Aubrey: [laughs] First, the state did it, and then employers are now like, "Wait a minute, me too."
Michael: It's also really frustrating, because as soon as anybody talks about universal healthcare in this country, corporations are some of the first ones to push back.
Aubrey: Yeah.
Michael: Because they like having this as a benefit that they can offer to recruit employees. It's like you realize this isn't helping you either. This sucks for literally everyone and it just keeps getting kicked down the road.
Aubrey: Yeah. Ugh.
Michael: So, the next 40 years are just more and more expansion and entrenchment of this concept. In 1979, we get a Surgeon General's report that identifies, "Work sites as an appropriate setting for health promotion." We start getting companies very publicly bragging about their workplace wellness programs. So, Johnson & Johnson is one of the first ones. In 1979, they launched this huge workplace wellness program that they've published a number of academic articles over the years about how it's so great, and their cost went down, and morale is up, and absenteeism is down, and everything's great. And We start getting studies throughout the 1980s and up until the 2000s showing that this saves money for employers. So, one of the early ones finds that companies save a $1.43 for every dollar that they spend on workplace wellness.
Aubrey: Oh, wow.
Michael: Another one comes out showing a $3.27 savings for every dollar they spend on health promotion. The most outlandish one I found was one that said that employers save $11. This is starting to look like something that is just like a win-win. It's good for employees, it's good for employers, and it pushes this responsibility off of the government, so the government loves it too.
Aubrey: But also, $11 for every one dollar is some real 400,000 Americans die of obesity every year kind of math where you're like, "How?"
Michael: Aubrey, don't imply that we're going to debunk these numbers later. I don't--
Aubrey: [laughs]
Michael: I'm livid that you'd assume that I'm giving you some numbers, but leaving out relevant content. Wow. Wow.
Aubrey: I can't believe that you would question an 11 to 1 return on investment.
Michael: The betrayal. My own cohost.
Aubrey: [laughs]
Michael: My own cohost.
Aubrey: At to Aubrey.
Michael: So, the next chapter of this story is basically the government having a bunch of opportunities to tamp down on this and do the right thing and just not doing it.
Aubrey: Oh, that's fun.
Michael: So, the 1990 Americans with Disabilities Act includes a specific carve out for workplace wellness programs.
Aubrey: Get the fuck out of here.
Michael: Mandatory physical examinations are prohibited by the Americans with Disabilities Act. However, it includes an exemption for voluntary medical examinations, including voluntary medical histories, which are part of an employee health program available to employees at the work site.
Aubrey: Nope.
Michael: So, it's like, as long as it's voluntary, it's chill.
Aubrey: As long as you're opting in to getting paid more, if you're not disabled. I'm just like, "This is fucked."
Michael: So, that's 1990. In 1996, we get HIPAA, which is mostly known now as the reason why your doctor can't give information about you to other people, but it also includes all these provisions to prevent discrimination in employer provided health insurance. But again, it includes a carve out for workplace wellness programs-
Aubrey: Garbage.
Michael: -as long as workplace wellness programs do not result in more than a 20% incentive. So, it all goes back to this issue of whether they're voluntary, because if your insurance is five times more expensive, if you don't pass all of these biometric things, you can say like, "Well, it's not meaningfully voluntary." You're basically coercing people into this with they have to pay more money.
Aubrey: Yeah.
Michael: So, HIPAA says 20%. If health insurance is costing people $500 a month, you can give them an incentive of up to $100 a month.
Aubrey: Gotcha.
Michael: That way it's voluntary, because it's not that much money or at least, that's the idea.
Aubrey: Yeah. Although, listen, we live in a country where in some cases, your healthcare costs can rival your housing costs, right?
Michael: Oh, yeah.
Aubrey: So, 20% of one of the biggest expenses in your life, I get where they're going with this logic, but it feels like it doesn't actually play out in people's real lives, right?
Michael: Right.
Aubrey: The idea that $100 a month is a negligible amount of money-
Michael: I know.
Aubrey: -is like bonkers.
Michael: It's also a very weird upside downity in that everyone would understand like, "Hey, disabled people have to pay more for this," as discrimination. That's just like straightforward discrimination, right?
Aubrey: Yeah.
Michael: But non-disabled people pay less for this. That's fine somehow.
Aubrey: Great. Cool. Good.
Michael: But it's like, I don't see how they're different. Ultimately, at the end of the day, disabled people are paying $500 a month and non-disabled people are paying $400 a month.
Aubrey: Yeah. Whatever you call that, there's a material reality that is being created here.
Michael: Right.
Aubrey: Yes, absolutely.
Michael: Another thing. This is foreshadowing alert [unintelligible [00:33:04].
Aubrey: [laughs]
Michael: HIPAA refuses to impose any regulations on workplace wellness programs. So, this isn't a really good history of this that I read. The final regulations added language providing that if a program has a reasonable chance of improving the health of participants is not overly burdensome, is not a subterfuge for discriminating based on a health factor, and is not highly suspect in the method chosen to promote health or prevent disease. It satisfies the standard. There does not need to be a scientific record that the method promotes wellness to satisfy the standard. So, basically, if you're trying to promote health, you can do any of these workplace wellness programs that you want. There's no quality assurance to offer this monetary incentive to employees.
Aubrey: Jesus Christ.
Michael: There's a long pause there. I was like, "Did Aubrey die?"
[laughter]
Michael: "Did I kill Aubrey?" [laughs]
Aubrey: No, I'm just tired. So, I used to work on this kind of stuff. The law is a broad statement of purpose. And where the law gets implemented is through regulations, which is where you go through all the stuff of like, "Okay, we told employers they can do this, where are we specifically setting the boundaries around that?"
Michael: Yeah.
Aubrey: We pass a law, people think that's the end of the work. That's the start of the work.
Michael: Wait, Aubrey--
Aubrey: What? Am I skipping ahead?
Michael: They do actually revisit this. So, you're about to be very happy-
Aubrey: Oh, okay.
Michael: -that they do revisit this, but they make it worse. I have an excerpt for you.
Aubrey: Oh, send me an excerpt.
Michael: So, context. HIPAA passes in 1996. Fast forward, Obama is elected in 2008, and one of his major campaign promises was reforming the healthcare system. So, throughout 2009, 2010, there's of course a huge debate of, what is healthcare reform going to look like? In the midst of this debate, in 2009, the Wall Street Journal publishes an op-ed by an executive at Safeway entitled how Safeway Is cutting health care costs. Market-based solutions can reduce the national healthcare bill by 40%. And I am going to send you a very boring and very long excerpt from this.
Aubrey: "Our plan utilizes a provision in the 1996 HIPAA law that permits employers to differentiate premiums based on behaviors. Currently, we are focused on tobacco usage, healthy weight, blood pressure, and cholesterol levels. Safeway's Healthy Measures program is completely voluntary and currently covers 74% of the insured non-union workforce."
Michael: Not foreshadowing.
Aubrey: "Employees are tested for cardiovascular disease, cancer, diabetes, and obesity, and receive premium discounts for each test they pass. If they pass all four tests, annual premiums are reduced $780 for individuals and $1,560 for families. Should they fail any or all tests, they can be tested again in 12 months." Wow. So, you get nothing?
Michael: But you can take the test again once you're healthy and clean.
Aubrey: Oh, congratulations. You were diabetic this time, but maybe not next time.
Michael: Have you tried biofeedback?
Aubrey: "The numbers speak for themselves. Our obesity and smoking rates are roughly 70% of the national average, and our healthcare costs for four years have held constant. Today, we are constrained by current laws from increasing these incentives." [Michael laughs] Argh. "We reward plan members $312 per year for not using tobacco, yet the annual cost of ensuring a tobacco user is $1,400. Reform legislation needs to raise the federal legal limits, so that incentives can better match the true incremental benefit of not engaging in these unhealthy behaviors." Holy shit. The number of logical fallacies here like, our workforce has 70% of the national average of X, Y, and Z thing, but those costs haven't gone down nationally. So, that just means you're employing more people who already had low healthcare costs?
Michael: Stop spoiling the debunking--[crosstalk]
Aubrey: [laughs]
Michael: Stop knowing things.
Aubrey: Sorry, sorry, sorry. This is astonishing and is like the narrative here is so fucking smart, which is, the law is standing in the way of employers who just want their employees to be as healthy as possible.
Michael: We can only offer 20% incentives.
Aubrey: Oh.
Michael and Aubrey: That's not enough.
Aubrey: We got to be able to reward. [crosstalk]
Michael: For larger ones.
Aubrey: Right. All of this is both predicated on and reinforcing the idea that, again, thin people and non-disabled people are doing right things and that any costs that an employer shoulders are the fault of fat people and disabled people, right?
Michael: Yes. This has totally been memory hole, but this was a huge part of the debate over Obamacare in 2009, 2010.
Aubrey: Really?
Michael: Yeah. Republicans started attacking Obama and saying like, "Oh, well, companies would like to offer more incentives to incentivize healthy behaviors, but they can't due to government regulations."
Aubrey: It's really amazing to me that all of them turned into Mrs. Lovejoy from The Simpsons and they all started going, "Won't someone please think of the Safeway CEO? What are we doing?"
Michael: Think of incentives.
Aubrey: Oh.
Michael: This became a huge deal. This Safeway CEO basically did a tour of Capitol Hill and met with a bunch of legislators, including Obama. In 2010, when they were debating the version of the Affordable Care Act that they had, they included something called the Safeway Amendment-
Aubrey: Shut the fuck up.
Michael: -that increased the incentives to 30%. In 2014, the average cost of insurance for a worker was $6,500 a year and the incentives are worth between $2,000 and $3,200. So, we're talking about a lot of money. That's what my first car cost.
Aubrey: Holy shit.
Michael: So, basically, this passed, this is in the Affordable Care Act.
Aubrey: I'm curious about in your research of this. Did you find much in the way of critiques of not how workplace wellness programs are implemented or regulated, but critiques of the existence of or the structure of workplace wellness programs?
Michael: Not until later. What was really frustrating in the reading for this episode was how much the cost logic seemed to dominate everything.
Aubrey: Yeah.
Michael: How much return do you get for this dollar of investment? There's a million of these and there's a million estimates of this, but qualitative research of like, what are these programs and what does it feel, and what are some of maybe the unintended harms of these? Almost nothing.
Aubrey: It's fascinating to me too, because I think this is one of the major narratives that drives our understanding of and response to fat people in the world. Fat people are most frequently discussed as a cost.
Michael: Right.
Aubrey: Nowhere in those conversations writ large is anyone going, "I wonder how fat people feel about this" or "I wonder if this is making things better or worse for them." So, people instead of having a conversation that is in any way grounded in anyone's humanity or in anyone's actual needs and responding to those needs or anything, those are treated not only as immaterial, but as distractions from solving the real problem, which is an economic problem.
Michael: So, before we debunk everything that we just went over, we're going to talk about the harms that have emerged and the forms of these programs that are really shitty and have started to proliferate. This is an excerpt from a congressional hearing in 2013 when the EEOC was thinking about doing something about this and ultimately decided not to. This is the kind of qualitative experience that just nobody is interested in for years. [laughs]
Aubrey: Yeah. Good. "Terry suffers from diabetes. And although, she passed all five fitness tests, she didn't meet the body mass index of 24. As a result, her employer imposed an increase in her family's insurance premium from $175 to $320 a month. After the birth of her baby, Terry's doctor warned that any weight loss was medically inadvisable while she was trying to manage both her diabetes and breastfeed. Since Terry's employer refused to exempt her from the BMI target and required her to work with a trainer outside of working hours, Terry was required to pay out of pocket for all these sessions and she continues to pay significantly more for her family's health insurance, a financial burden not placed upon other employees." Yeah.
Michael: Yeah.
Aubrey: Fucking fix it for Terry.
Michael: So, you basically have somebody who's like, "She has diabetes and she's paying more."
Aubrey: Yeah.
Michael: This is exactly the scenario that three different laws now have sought to avoid.
Aubrey: Right. So, any person with a chronic illness will be able to plug in somewhere to this story. But I would also like to propose that any person who has given birth and cared for an infant can also fucking plug into this story and go, "Hey, imagine if your employer said, on top of caring for an infant, you also need to show up with a personal trainer a number of times a week and pay for it out of pocket."'
Michael: Wild.
Aubrey: Get the fuck out of here.
Michael: There's also an interesting sentence here where it says, "Terry's employer refused to exempt her from the BMI target."
Aubrey: Yeah.
Michael: So, in HIPAA, it says that, "If you're not able to participate in these wellness programs, you get an exemption." If your workplace is doing one of these things where you get a bonus for doing 10,000 steps a day and you're in a wheelchair, obviously, you can't participate in that, so you get an exemption. However, it didn't define who's qualified for an exemption, what an exemption counts as, when it should be offered, etc. It just says like, employers should offer an exemption. But what we find in the real world is that, oftentimes, when employees ask for exemptions, "Hey, I have another job. I can't do 10,000 steps." They're often not given them, because they're not considered to be a "real reason."
Aubrey: Jesus.
Michael: This is an excerpt from a very good legal analysis of all three of these laws that I read and how they relate workplace wellness programs. You can hear the exasperation in this paragraph. It says, "Wellness programs are difficult to reconcile with a number of federal laws that aim to restrict employers' ability to discriminate among their employees in the provision of health insurance."
Aubrey: Good.
Michael: "After all, the point of wellness programs is to discriminate those employees, who adhere to the wellness program, whether by filling out a detailed health assessment, taking a blood test, or attending smoking cessation courses, pay less for their health coverage. Those who do not, pay more."
Aubrey: Yeah.
Michael: It's this amazing article that's just like a legal scholar looking at all this shit and being like, "Guys, I think this is illegal." [laughs]
Aubrey: That quote, the point of these programs is to discriminate is a real say it louder for the people in the fucking back.
Michael: That's what they do.
Aubrey: That is what they are here to do.
Michael: So, the last excerpt from our emails that I want to read, Aubrey, there's so much here. There's so much that we're going to cover in the bonus episode. These programs are so fucking trash. But one of the main things that we heard, especially from fat listeners, was the sheer cancerousness of weight loss contests.
Aubrey: Yeah. The number of workplace biggest loser competitions that are out there make me want to just barf myself to death. I don't even know. I'm so-
Michael: It's so bad.
Aubrey: -repulsed.
Michael: This is just one of the emails that we got.
Aubrey: "I have been with the same company for 20 years. And the last five, there has been some sort of get healthy New Year's resolution. Last year, it was a diet bet. If you're not familiar, it's done via an app. A group creates a diet bet, everyone puts their money in, and the people who hit their goal weight at the end split the pot. As one of the few fat people at my workplace, it was 1000% expected that I would participate. I did not, because eating disorder and also, fuck all of that."
Michael: Our listeners are cool.
Aubrey: "'But it's only $10. Don't you want to get healthy with us? You'll feel so much better. You would be so inspirational to everyone.' Not kidding about that last one. Finally, it started without me. But for the two months, it went on. No one would shut up about their food and exercise, measurements and weight, alternately talking about what they were going to eat when it was over, calling it a lifestyle change, crowing about feeling so much better and quietly crying, because they were fucking hungry. All jokes aside, it was awful and stressful, and the amount of side eye I got for eating normal amounts of food led me to never again eating anything in front of co-workers. Still don't. Maybe I was imagining it, but it felt like waves of anger coming from a starving mob that might, in fact, push me down a flight of stairs for my lunch."
Michael: Do not do this to people in the workplace.
Aubrey: Not eating in front of people is such a deep fat people thing and it is a direct result of how other people treat you. It is also a thing that is a direct path to eating disorder behavior or eating disorder relapse behavior is like hiding your food or eating in private or in secret, right?
Michael: Yeah.
Aubrey: Fat people do that, not because of some internal drive, maybe sometimes. But overwhelmingly that is prompted by direct behavior from people in their lives. That's fucking horrible. I'm so sorry to this listener.
Michael: I'm breaking my own rule and reading one more, because I can't help myself.
Aubrey: Great. Good.
Michael: This is a really awful one. I feel it's such a perfect example of why these are so bad. "A couple of years ago, we had an open cubicle where someone would bring in treats and there was a coffee maker too. Someone had put a scale on the floor and-
Aubrey: Fuck off.
Michael: -put a food diary/chart to track their intake. I posted a paper near it saying, 'This is a communal food space and having the scale and food diary is inappropriate and could be upsetting for people experiencing eating disorders.' I did it anonymously, because I didn't want to be the fat lady complaining about a scale. I was able to overhear when someone reported it to the manager, who then talked to HR. I saw the email response from HR to the manager and their stance was basically, if someone has an eating disorder, they need to report it and get an accommodation. What would an accommodation for that even be?"
So, this is another thing that comes up in a lot of the emails that we got from fat people and disabled people was that these workplace wellness programs, even though technically, they are supposed to provide exemptions for people who can't or don't want to participate. What they do is, they make you disclose disabilities to your manager. One lady who had IBS had to tell her boss like, "I have IBS and I can't do this, because I have to go to the bathroom a lot." That's not something you necessarily want to disclose to your manager who's in charge of promotions and shit. This is an invitation to discriminate against people like, "Hi, there. There's this thing that people get discriminated against a lot and I have it."
Aubrey: Well, and also, to the email that you sent to me about the person doing this diet bet business, you don't need an exemption from that. That is a voluntary program. This person opted out and it still made things fucking horrible for them.
Michael: Exactly.
Aubrey: Listen, I understand that this is not the legal definition, but I would interpret on an emotional, personal level all of this shit as an extraordinarily hostile workplace.
Michael: Oh, super-duper. Yeah, and it's this hostility that's like, "What's your problem? It's fun."
Aubrey: Yeah.
Michael: It puts you in this position where you have to be like, "This isn't fun for me."
Aubrey: Totally. It feels there's something about that, "Come on, we're just having a good time." That feels like an echo of what alcoholics will describe when they tell someone they're not going to drink.
Michael: Right.
Aubrey: People go, "Come on, loosen up. It's just one drink, blah, blah." I'm like, "Why are you so invested in overriding this person's own decision about how to relate to this situation?" It is really astonishing and feels like, again, there are these moments around fatness and disability and a number of these issues where even the most thoughtfully relational people, even the people with the sharpest interpersonal radars will just turn their fucking brains off when it comes to this issue and go-
Michael: Yeah, it's wild.
Aubrey: -"It's for your own good. Why aren't you grateful? We're just having a good time. I'm just concerned about your health." Which is why I have to keep ignoring what you're directly asking me not to do and do it anyway.
Michael: So, we've talked about some of the harms of these programs. But we should also say, on the other hand, there is no evidence that they work at all.
Aubrey: [laughs]
Michael: So, at least-- [crosstalk]
Aubrey: In fairness, they might be entirely useless.
Michael: Completely useless at best. The first thing we need to debunk of everything we've gone over in the history of this is that Safeway was fucking lying.
Aubrey: Yeah. There we go. Yeah.
Michael: So, it turns out that Safeway's healthcare costs did in fact decrease. They decreased in 2006, three years before they launched their workplace wellness program, [Aubrey laughs] because they shifted a bunch of the costs to employees.
Aubrey: Yeah. They did what every major employer was doing at that time, which is breaking it to their employees that they were going to have to chip in hundreds of dollars a month-
Michael: Exactly.
Aubrey: -for something that was previously free or way lower cost.
Michael: So, it's like, they raise your deductible, they have different yearly limits. A lot of employers do this in this sneaky way. Also, when they said in that excerpt that it was our non-union health insured employees, it turned out to be something like 2% of their workforce.
Aubrey: Right. Non-union either means they have such a low level of hours that they're not represented.
Michael: Right.
Aubrey: Or, it means they're fucking management. Either way, that's not a representative picture.
Michael: So, just complete bullshit. The most amazing and frustrating thing about this is that the Washington Post investigation that reveals all of this and interviews some sub-CEO person at Safeway who's like, "Oh, yeah, we were lying." Just like full on-
Aubrey: [laughs]
Michael: -just like, "Oh, yeah, when we said that were lying, basically." All of that came out months before the Affordable Care Act was passed. When the Safeway Amendment was put into the law, we knew that Safeway was fucking lying and it just didn't matter. The second thing that we know now and pretended not to know then is that, none of these programs really work. So, I read a million meta-analyses, whatever of the weight loss stuff. This is a paragraph from Health Affairs that I feel like either one of us could fucking lip sync along to.
Aubrey: Uh-huh.
Michael: It says, "A meta-analysis of seven trials found that workplace financial incentives were associated with a mean weight loss of 0.88 of a pound at 12 months, and 1.5 pounds at 18 months, and a weighted mean gain of 4.2 pounds at 30-month, although none of the results were significant."
Aubrey: Great. I love the little like, "Hey guys, here are all the amazing results. None of them are significant." [mumbling]
Michael: There's another meta-analysis that finds a reduction of 2.8 pounds after 12 months, which, if you look at the average weight of the average American, it's something like 175 pounds. So, this is a 2% weight loss.
Aubrey: Great. Good. Good, good, good, good.
Michael: Also, none of the money saving like $3 for every dollar you spend, none of that shit pans out. So, there's a 2013 Health Affairs study that says, "Program savings may not, in fact, derive from health improvements. Instead, they may come from making workers with health risks pay more for their healthcare than workers without health risks."
Aubrey: Fucking gross.
Michael: Great. Charging them more. There's a 2013 RAND study that says, "At this point in time, there is insufficient objective evidence to definitively assess the impact of workplace wellness on health outcomes and cost."
Aubrey: Good.
Michael: In 2018, there's yet another Health Affairs meta-analysis that says, "We conclude that these programs increase rather than decrease employer spending on healthcare with no net health benefit. The programs also cause over-utilization of screening and check-ups, put undue stress on employees, and incentivize unhealthy forms of weight loss."
Aubrey: It's not just discriminatory, it's also ineffective.
Michael: Wonderful shit. I want to talk briefly about why these don't appear to work. There's four reasons why none of this shit has panned out. The first is selection bias. If you go through Google Scholar and you just type in "workplace wellness program," most of them show that it works. There's one from Home Depot that works, there's one from Pepsi that works, there's one from IBM that works. But the problem with all of these is that they're voluntary to participate. So, what you have is you have really low participation rates. The IBM one only has 4.8% of the workforce participates. There's one at the University of Illinois, where 25% of people participate the first year, but then it's down to 10% by the second year.
What these are basically doing is they're selecting for people who are already "healthy to begin with." So, someone like me like, "I already go to the gym," if my workplace says like, "Oh, we're going to pay your gym membership and you have to go to three Zoom meetings a year and we'll pay 90 bucks a month for your gym membership tax free," I'd be like, "Yeah, sure."
Aubrey: Totally.
Michael: But it's like, "I'm somebody who already has a gym membership."
Aubrey: "I am also somebody who would not go to a fucking gym, not because I don't enjoy to do any of the things that happen at a gym, but because aside from a very few and very select exceptions. Gyms are like terrible fucking places to be as a fat person.
Michael: Dude, [crosstalk] awful.
Aubrey: The social experience of being at a gym means maybe somebody takes your picture, because they think it's funny to watch you working out. Maybe somebody else feels pity for you and thinks that the best thing they could do for you is go, "Good for you. Keep it up. You'll get there."
Michael: Man, it's awful.
Aubrey: On top of that, if you also had any kind of mobility issues, if you also had any-
Michael: Exactly.
Aubrey: -specific accessibility needs, you couldn't and wouldn't take that discount, because it doesn't fucking work for you, because the gym doesn't fucking work for you.
Michael: So, basically when you go back and you re-analyze the numbers from all of these like "it worked" studies, what you find is that most of the people who have lower healthcare costs after the program had lower healthcare costs before the program.
Aubrey: Right.
Michael: Because these are people without chronic illnesses and disabilities and stuff, they're like the "healthy people," anyway. So, all you're really doing is giving more money to the healthy people. So, that's reason one that these don't work. The second reason, this doesn't fit the format all that well, but I just wanted to talk about it with you because it's hella funny.
Aubrey: Great.
Michael: Most of the studies are based entirely on self-report data, which as we've discussed in the show 10,000 times is just like complete fucking garbage. There's a couple of actually genuinely well-designed studies that are randomized. There's one at a warehouse company that is an 18-month program, and people are randomized either in it or not in it. So, it's a pretty good design. At the end of 18 months, they find that the only difference between treatment and control is a higher proportion of people who reported engaging in regular exercise and who reported actively managing their weight. The study did not affect cholesterol levels, hypertension, obesity, absenteeism, or performance reviews. [Aubrey laughs] So, the measurable the stuff that we can measure.
Aubrey: Right. So, what it does do is make more people tell us what we told them we wanted to hear-
Michael: Exactly.
Aubrey: -and we would pay them if they told us those things.
Michael: Then, this is something we come across all the fucking time on this podcast. These studies will say like, "Well, it affected these totally bullshit indicators and it didn't affect these real indicators and what we set out to do. So, the findings are mixed."
Aubrey: Yeah. Good.
Michael: So, the conclusion of this study says that, "The program affected self-reported health behaviors, but not health or economic outcomes may be interpreted in several ways. Given that workplace wellness programs focus on changing behavior and that behavior change may proceed improvements in other outcomes, these findings could be consistent with future improvements in health or reductions in spending."
Aubrey: "Listen, ma'am, the checks in the mail [Michael laughs] just hasn't gotten to you yet. Don't worry about it." Argh.
Michael: Okay. Listen to this. This is maybe one too many examples, but I like to want to have it on the record. So, this is the conclusion of a huge, also fairly well-designed randomized control trial at the University of Illinois that was called iTHRIVE, because it's like the mid-2000s, it's like a little I like iPod, like--[crosstalk]
Aubrey: Good.
Michael: Amazing. So, the study finds essentially no benefit other than this self-reported garbage and no effect on actual measurable health metrics. So, this is a conclusion. It says, "Does this mean that employers should abandon wellness programs? It depends on what they're trying to achieve. Workers seemed to value as a benefit and were more attuned to the importance of healthy behaviors and made efforts to act accordingly. If employers are seeking to add benefits that workers value or to attract the type of worker who appreciates those benefits, the programs may be worth it. But if the goal is to save money by reducing healthcare costs and absenteeism or to improve chronic physical health conditions, there is little evidence of this type of program delivers the desired results." So, if you want to tell people that this works, great. [Aubrey laughs] If you want to do something that works.
Aubrey: Well, I also like that it's like, "Well, employees report X, Y, and Z things." I'm like, "Yeah, employees report liking not having to spend extra hundreds of dollars every year."
Michael: The obvious conclusion from this is that these programs are fucking bullshit and they don't do anything. But all of these papers refuse to reach the obvious conclusion. They're like, "Well, if you're looking for something that manages healthcare costs and makes people healthier, I don't know if this is the right thing for you." It's like, "Well, then why are we doing? What other reason is there to do it?"
Aubrey: You know what this episode feels like to me? Do you know those cartoons where a cartoon character will fall through the roof and then hit a floor, and then the floor will give way, and then it'll hit the next floor down, and then finally they end up on an awning and the awning gives way or whatever.
Michael: Yeah.
Aubrey: This feels like that as a logic model for policy making, [Michael laughs] where it's just like every possible justification for these programs has been pulled away from them. Every possible support that these could have had have been taken away and now they're just somehow levitating in mid-air and they're still there.
Michael: But wait, there's more.
Aubrey: Oh, no, Mike.
Michael: So, most of what we've gone over so far is reasons why workplace wellness programs are bad. This isn't really one of them. This is more just why workplace wellness programs don't work, why they don't make people healthier or save employers money.
Aubrey: Uh-huh.
Michael: Workplace wellness is a wildly grifty sector, because the HIPAA law refused to impose any standards on the industry. These don't have to be backed up by science. There's an entire sector that is workplace wellness consultants. These are usually done through third party firms. There's essentially no regulation of the content of these programs. So, a lot of these firms are basically like used car salesman shit. They bring weird gurus into the workplace. One person who wrote us said they had to be on a Zoom call with somebody who said that you have to drink six glasses of water every day, because if you don't, you start circulating dirty water in your body.
Aubrey: [laughs] "Hey man, you got to flush out your boiler every week. Otherwise, you're going to start circulating rusty water through there." Wow.
Michael: One of the first baseline things that you have to do to get these monetary incentives is to go get a health risk assessment screening. So, the idea is you get an incentive for going and having annual physical and then that allows you to identify things before they become big problems. As a principle, this sounds totally uncontroversial. Go get a health screening every year. Great. The problem is there's no actual standards for what constitutes annual physical.
Aubrey: Excellent.
Michael: So, even within the medical field, this isn't very well defined. Secondly, these grifty ass workplace wellness consultants are sending people to get these weird fucking tests for rare, strange conditions. So, there's reports of people having their kidneys removed, because they tested positive for some kidney, blood disease, something, something, but it's just a false positive.
Aubrey: God. This is like your workplace wellness program as designed by Elizabeth Holmes.
Michael: I don't want to overstate this or make people think that getting a physical is always a bad idea. The literature seems to say that if you have a condition that needs to be monitored, obviously, you should regularly see a doctor, if you're somebody who hasn't seen a doctor in a while. A lot of poor people in America do not have regular contact with the healthcare system.
Aubrey: Yeah.
Michael: Basically, if there's a reason to go to the doctor, go to the doctor. But what we're talking about in these workplace wellness programs is "healthy people" going to see a doctor every single year. The more people do that, the more they increase their chances of testing positive for something. The central problem with the incentives here is that these workplace wellness consulting firms want to demonstrate to the employers that they're having value. There's a Nebraska program that says, "We prevented it was like 400 cases of colon cancer." Like, "Oh, look, we're prolonging the life of your employees and look how great this is." Later on, it turns out that the firm was just faking their data.
Aubrey: Shut the fuck up.
Michael: The problem with the US healthcare system is because it's a fee for service model, people only get paid if they're providing a service. Oftentimes, people go in and the doctor is like, "Oh, you need to come back next week for this thing. We're going to screen you for this just in case." Some of what gets called over treatment in America is actually treatment for people. This is like a fucked up and ableist narrative. But also, there is a lot of overtreatments in the US healthcare system. So, basically, you're just shunting people into these grifty sectors that are going to do a bunch of weird fucking tests and produce a bunch of positives and then have a bunch of weird follow up procedures that might not actually be necessary.
Aubrey: Well, and that also seems less like an issue of overtreatment and more like an issue of bad treatment from people who should have to have some kind of qualification.
Michael: Right. It shouldn't be going through the like, "Beware of dirty water, people." Those people should not be involved.
Aubrey: Yeah, that's right.
Michael: So, the last reason why these don't work is basically the wellness paradigm itself. Throughout the 1970s and 1980s, as we were getting this wellness model, we were getting this list of lifestyle risk factors that affect chronic illness. What happened is, we started conflating the risk factors for causes.
Aubrey: Yes.
Michael: What you hear a lot is that obesity is a risk factor for heart disease. So, that makes you think that, "Well, if we reduce the obesity, we'll reduce the heart disease." But that doesn't actually turn out to be true. So, a lot of these studies find that fat people cost more to treat in their healthcare than skinny people overall. However, their costs do not go down when they lose weight, because it is not necessarily the fat that is causing the health problems. You can't change somebody's health by changing their risk factor. It's like saying, people in Connecticut have a 10-year longer life expectancy than people in Mississippi. That doesn't mean that forcing people to move from Mississippi to Connecticut will give them as individuals 10 years more on their life.
Aubrey: Well, and to this point about overtreatment/bad treatment, all of this business about fat people costing so much more money does not account for the very frequent experience of fat people of going into a doctor's office, not getting any new diagnoses, not being diagnosed with diabetes or PCOS or any number of things, but still walking out with a prescription for metformin.
Michael: Right.
Aubrey: Also, the cost of treatment of fat people are also kind of the cost of our assumptions about what being fat means about your health.
Michael: It also doesn't acknowledge the actual reasons that are driving US healthcare spending. A lot of healthcare spending is actually driven by hospitalizations and people have gone through and looked at these kind of chronic risk factors. There's a study in 2012 that looked at cholesterol, blood pressure, et cetera. All of these kinds of these factors that we associate with chronic illness, they only account for about 20% of healthcare spending.
Aubrey: It also seems that the further and further we go down these paths of more and better research into diabetes and heart disease and all of these sorts of things that we have been taught are the direct result of "lifestyle factors" is that quite a few of them are much more genetically driven or driven by social determinants of health. We are saying that we care about costs, we are never looking at a balance sheet. We're just going, "It's got to be fat people and disabled people. Get them out of here."
Michael: So, I want to end with the one area where this does work and then a happy ending.
Aubrey: Tell me.
Michael: The only aspect of workplace wellness that I could find that's effective appears to be these smoking cessation programs.
Aubrey: Oh, interesting.
Michael: They're not like the most effective mostly because quitting smoking is just really hard and the relapse rates are high. Yeah, people who are enrolled in smoking cessation programs have higher rates of quitting. What's interesting once you read the studies on this is, it's not the fact that they're like workplace quit smoking programs. They're just quit smoking programs. All of the stuff about the posters in the workplace or having your boss involved, having your employer as some sort of participant in you quitting smoking really doesn't add anything. So, even if you do believe that they work, they work for people who have high paying jobs with really good health benefits. But if we just had universal healthcare, hospitals could just provide it to people who needed it.
Aubrey: Yeah, totally.
Michael: I actually think that smoking is such a great example of the original sin of these, because smoking is very well established as a behavior that is really bad for you. It is also, in my estimation, none of my employer's business. If I want to smoke when I'm not on the clock, who cares? That doesn't affect my job performance at all. So, why would my employer be anywhere within 50 feet of this decision of mine to keep smoking?
Aubrey: Well, it's all an end run around this fundamental miscalculation that has been made or this fundamental like avoidance of a fundamental truth maybe is the way to put it, which is that, if you care about improving the health of a population, you need to provide healthcare and access to treatment for every part of that population. We as a country keep refusing that very clear lesson, time and time and time again.
Michael: Right. People seem weirdly surprised that a health intervention designed to only reach thin, rich people with office jobs.
Aubrey: [laughs]
Michael: I was like, "Wait, what do you mean it's not working? Hang on." So, the happy ending of this episode, we get so few of these.
Aubrey: Oh, what a twist.
Michael: Basically, people fucking hate these programs and there's [Aubrey laughs] a massive backlash. A huge number of the people who wrote in to us did tiny acts of resistance. A lot of people, numerous people put their weight as 50 pounds on their [Aubrey laughs] workplace wellness program thing.
Aubrey: [laughs]
Michael: They're like, "Fuck you. My BMI is nowhere near any of your business. I am 5'10", 50 pounds. Fuck you." [laughs]
Aubrey: Yeah, good job.
Michael: What I liked to see is that there's finally starting to be articles about workplace wellness programs that aren't just doing the fake confusion thing like, "Oh, weird. It turns out that nobody lost weight on a weight loss program." There's an academic article called Employers Should Disband Employee Weight Control Programs.
Aubrey: Good.
Michael: People are finally coming to the obvious conclusion from years of data that just like, "This suck and shouldn't exist. They're totally unjustifiable. We implemented them on extremely thin information. The evidence is wildly consistent now. They don't work. They suck. They're making things worse for everybody. Let's not do this anymore."
Aubrey: Yeah. And on top of all that, they're not only discriminatory. They're not only proudly discriminatory, but they are developed for the purpose of discriminating and that's their main selling point.
Michael: Exactly. If they work, that is why.
Aubrey: This is not a case of like, "Oh, we've really been bamboozled into thinking that this thing is okay."
Michael: Right.
Aubrey: No, everyone's been saying the quiet part loud this entire time.
Michael: Right.
Aubrey: Yeah. I think I'm so glad to hear that there is some kind of emerging like, "Oh, wait a minute, we should stop this."
Michael: But, Aubrey, how else are we going to know about all the dirty water [crosstalk] this?
Aubrey: [laughs]
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