Alabama 'Obesity Penalty' Stirs Debate

Plan Calls for State Employees to Pay More for Health Insurance if They Don't Lose Weight

From the WebMD Archives

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.

Employees and Employers: Seeking Obesity Solutions

A recent survey conducted by the National Opinion Research Center (NORC) at the University of Chicago, partnered on the research with the George Washington University School of Public Health and Health Services , showed that:

  • 80% of employees, regardless of weight, believe healthy lifestyles/weight management programs belong in the workplace.
  • 67% of employers are concerned about obesity's effect on medical claims expenses.
  • 93% of employers see obesity as a preventable condition and due to poor lifestyle choices.
  • Fewer than half of employers believe their company has given enough attention to the problem of obesity.

Christy Ferguson, director of the STOP Obesity Alliance in Washington, D.C., which commissioned the survey, tells WebMD that while employers are eager to promote weight loss, only about a quarter of those surveyed believe financial penalties should be placed on those who have difficulty succeeding.

"While employers and employees favor positive financial incentives, they oppose negative financial penalties," she says. "There's a strong support for the carrot, so to speak, and not-so-strong support for the stick."

Key in all of these programs and findings is that shedding excess pounds is intrinsic to good health. But does thin and trim always equal fit and healthy?

A report released this month by The Archives of Internal Medicine, which weighed cardiometabolic risk factors vs. weight, revealed that among the 5,440 participants -- U.S. adults 20 years old and older -- 23.5% of "normal weight" adults were metabolically abnormal. Conversely, 51.3% of adults deemed overweight and 31.7% classified as obese were declared "metabolically healthy."

Lifestyle and activity levels certainly vary between individuals, but the link between weight and health doesn't appear to be absolute. And unlike many conditions which remain discrete, obesity is on full display.

"I don't think we can arbitrarily pick out one specific set of people with health risks," San Francisco internist Ann Haiden, MD, tells WebMD. "There is evidence that fit people with a little excess weight can actually be healthier than unhealthy normal-weight people. What we don't need is for a policy like this to turn into yet another reason to exclude as many people as possible from the insurance pool."

Even with a $25 monthly bill, Alabama state workers boast a plum health care plan. Single state employees pay no insurance fees, Unger says, while family plans -- which can include a spouse and several children -- only cost $180 per month. Spouses and children of state workers will not be subject to the wellness screenings.

Legally, these new protocols could face few serious threats.

Myra Creighton, an Atlanta labor and employment attorney who specializes in health-related issues, says many people are unsympathetic to obese individuals, which could make civil liberties organizations reluctant to pursue opposition. Michigan, she says, is the only state where weight is categorized as a protected class for workers.


Ethical Issues of Penalty Proposal

Still, she does question certain ethical aspects of these actions.

"Do I have any privacy interests in my body weight?" Creighton says. "I'm just glad my firm doesn't require me to hop on a scale."

While the converted are often the most zealous agents for change, one Alabama resident who triumphed against the scale finds the state requirements somewhat troubling.

Enterprise, Ala.-resident Roger Shultz, this year's runner-up on the NBC TV show The Biggest Loser, nearly cut his formerly obese physique in half while appearing on the show. Shultz, who lost 164 pounds, has kept his 6-foot-3-inch frame at a lean 222 pounds since the show ended. He's now a spokesman for Scale Back Alabama, a state-sponsored campaign that promotes weight loss and exercise.

Keeping trim in Alabama is sometimes challenging: "We deep-fry everything," he tells WebMD. But instituting fines for failing doesn't seem like the right step to him.

"I worked for a state institution and I'd hate to see something monetarily taken away from me," says, Shultz, who was employed at two Alabama colleges. "We have to be healthy, but I don't think you should penalize people for being heavy."

WebMD Health News Reviewed by Louise Chang, MD on August 25, 2008



Jeffrey Levi, PhD, executive director, Trust for America's Health; associate professor of health policy, George Washington University School of Public Health , Washington, D.C.

Deborah Unger, clinical director, Alabama State Employees Insurance Board, Montgomery.

Press-Register: "State does poor in obesity survey."

CDC: "U.S. Obesity Trends 1985-2007."

"Costs Driving Employer Action Against Obesity," National Opinion Research Center at the University of Chicago in conjunction with The George Washington University School of Public Health and Health Services.

Christy Ferguson, director, STOP Obesity Alliance, Washington, D.C.

Wildman, R. Archives of Internal Medicine, Aug. 11/25, 2008; vol 168: pp 1617-1624.

Ann Haiden, MD, internist, San Francisco.

The New York Times: "Better to be fat and fit than skinny and unfit."

Roger Shultz, runner-up, NBC's The Biggest Loser, Enterprise, Ala.

© 2008 WebMD, LLC. All rights reserved.


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