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Alabama 'Obesity Penalty' Stirs Debate

Plan Calls for State Employees to Pay More for Health Insurance if They Don't Lose Weight
By Don Fernandez
WebMD Health News
Reviewed by Louise Chang, MD

Aug. 25, 2008 -- Obese Alabama state workers may soon pay a health insurance penalty for their excess pounds.

Beginning in January 2009, state employees will be required to receive medical screenings for several conditions, including body mass index (BMI). Those who are considered obese -- along with exhibiting other negative health factors -- will have a year to get in shape.

The penalty for failure? A $25 increase in their monthly insurance costs.

Although critics view the penalty as a "fat tax," Alabama officials believe the new policies will result in fitter, healthier, and happier employees -- as well as help reduce the state's mounting health care costs.

"Our goal was to make our members aware of those risk factors," Deborah Unger, RN, clinical director for the Alabama State Employees Insurance Board in Montgomery, tells WebMD. "As long as you are aware and are doing something to correct it, there won't be a fee. We either do something to control claims costs or you pay the premium anyway."

Alabama now ranks as the second most obese state in the U.S., according to the CDC -- perhaps a clear sign that change is needed. In addition to BMI, the state will screen three additional criteria: cholesterol, blood pressure, and glucose levels. These four risk factors have consistently resulted in costly treatments for the state.

Opponents of the Obesity Penalty

While the plan might seem practical, some experts question whether paying a fee for being obese is the best motivator for overweight people.

"We certainly wouldn't support these kinds of punitive measures," says Jeffrey Levi, PhD, executive director of Trust for America's Health and associate professor of health policy at George Washington University School of Public Health. "The successful measures by health plans focus on incentives rather than punishment."

The Alabama requirements, Levi tells WebMD, could be interpreted as a genetic penalty for those who are predisposed to having extra weight or high cholesterol. Some people also require a variety of treatments or medications before finding one that is effective. Making those who fail pay from their pockets also places more economic pressure on them, he says, which could lead them to turn to cheaper, calorie-dense food.

"We need to recognize the complexity of these things," Levi says. "Just addressing this through the health care system is insufficient. What are we doing about the workplace environment? What's served in state cafeterias and hospitals? We need to do the voluntary things first for people to be able to make healthy choices before forcing punitive measures."

Alabama employees at risk will receive some help in their quest. The state is arranging programs with Weight Watchers and offering employees YMCA discounts. Information will also be available at, a Blue Cross-Blue Shield web site that provides online wellness tools and news.

But the prime motivator for this policy is hefty health care costs. And the attitudes of employers and employees may reflect an ambition to help remove obesity from the equation.

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