Laura Rowley Money & Happiness

Last week, in the moral values class I teach at Seton Hall University, we discussed how some decisions that used to be considered lifestyle choices, such as smoking, have become moralized and issues that were once moralized by society, such as couples living together without being married, have become lifestyle choices.

As Harvard psychology professor Steven Pinker writes, moralization is the mindset that makes things wrong and taboo (violent crime) vs. merely disagreeable (blabbing on a cell phone while riding public transportation).

But what is it that makes something a moral, rather than a lifestyle, issue? In the case of smoking, Pinker has noted, it's the unfair harm caused to other people. The discovery that second-hand smoke could damage the health of innocent bystanders transformed the act from one of a personal (if highly risky) preference into a moral hazard, addressed by a host of new laws banning smoking in airplanes, office buildings, restaurants, bars and the like.

My hunch is that personal health -- choices like eating junk food and not exercising -- is rising on the moralization radar, because the irresponsible choices of some play a role in the skyrocketing costs for everyone else. Consider that 5 percent of Americans account for 49 percent of the medical spending, according to a study by the Department of Health and Human Services, while half of the population in the U.S. spends little or nothing on health care.

The Centers for Disease Control says chronic conditions, which include heart disease, stroke, hypertension and diabetes, are among "the most prevalent, costly and preventable of all health problems." Patients with multiple chronic conditions cost up to seven times as much as patients with only one chronic condition. The total cost of obesity alone was $117 billion in 2000, the CDC found.

Part of this problem is caused by the food system and farm policies in the U.S. As author Michael Pollan noted in The New York Times last week: "… the government is putting itself in the uncomfortable position of subsidizing both the costs of treating Type 2 diabetes and the consumption of high-fructose corn syrup." There are also issues of education and disclosure. I suspected a Starbucks cranberry muffin was fattening, but didn't know it packed more than 400 calories and 20 grams of fat until New York City made restaurant chains put their calories on the menu.

But part of the health issue is due to personal choices about what to eat and drink and what to do with one's time, and that's where you'll find creeping moralization. A 2006 survey by The Wall Street Journal found 53 percent of adults thought it was "fair" to charge lower insurance premiums and co-pays to "people who have healthy lifestyles, don't smoke, exercise frequently and control their weight (and) tend to incur fewer health care costs than people with unhealthy lifestyles." Only 32 percent disagreed. Three years earlier, the findings were reversed: 37 percent said it would be fair and 46 percent said it would be unfair.

The moralization of personal health is beginning to show up in the workplace in the form of wellness programs, of both the carrot and stick variety. According to a MetLife survey, 61 percent of employers with 10,000 or more workers offered such programs in 2008, up from 47 percent in 2005.

Wellness programs "ask, require or provide incentives for employees to fill out health-risk assessments to identify health issues; the results do not go to the employer but to a third party," says Paul Fronstin, director of health research programs at the Employee Benefits Research Institute. "They then try to engage people. Someone at risk for heart disease or with blood pressure or body mass over a certain level might get a health coach and help changing their lifestyle. They either get paid to participate or get penalized if they don't participate."

For example, Virgin HealthMiles, a third-party wellness firm and part of the Virgin Group, has 500,000 members in the U.S. who earn points for becoming active and tracking their health. Members use tools such as pedometers to record their activity and visit measurement stations to track their weight, blood pressure, body fat and body mass index. Each participant has a personal online program portal where they can set up challenges and redeem rewards, including cash. Employers have access to aggregate, not individual, results.

Janet Lewellyn, director of the Shawano County Health Department in Wisconsin, brought in Virgin HealthMiles last April. County employees can earn up to $300 in cash by participating, though they pay to play ($5 a month, deducted from their paychecks). The county also negotiated a rebate from its health insurance provider, "so the cost to the county is very minimal," Lewellyn says. About 100 of the county's 466 employees have signed on.

"The mantra around here is 'we're in it for the money,'" says Lewellyn. "People discuss how many dollars they have in their HealthMiles accounts and the competitions that allow you to get extra health miles. The county is certainly in it for the money because our goal is to reduce our health care cost, or at least stabilize it." Workers get reward points for tracking and entering their data, whether their numbers have improved or not. 

Lewellyn says obesity rates declined in the first four months of the program. "Years ago during breaks people would be sitting in the break room eating things that weren't nutritious and drinking caffeinated beverages and now you see groups walking around together," she says.

But some Virgin clients are funding the programs by increasing costs for non-participants. "Today all workers have co-pays to participate in company health programs," says HealthMiles president Sean Forbes. "Using this platform, companies can dictate the amount of the co-pay based on how much activity their employees are getting -- so you effectively have some that aren't doing their part funding the entire program, including the rewards."

Forbes says that his program helps establish an essential link between health insurance costs and behavior. People who take care of their health "are paying a big tax, and it doesn't feel fair," he argues. "I get asked all the time if (the program) feels punitive because you'll have people who end up paying more. But it's a choice they get to make. They can choose to be more active and most likely, more healthy, or they can choose not to. But as a country we can no longer afford not to have a price for risky behavior and the costs that come after it."

What do you think? Should people who choose unhealthy lifestyles pay more for health insurance? Are people more likely to change their behavior when their choices have a direct impact on their wallets?