Maintenance Phase - Workplace Wellness

Episode Date: December 20, 2022

Charging disabled people more for health care is illegal. But what about ... charging non-disabled people less?Support us:Hear bonus episodes on PatreonDonate on PayPalGet Maintenance Phase T-shirts, stickers and moreBuy Aubrey's new bookListen to Mike's new podcastLinks! A Review of the U.S. Workplace Wellness Market"Wellness" Based Healthcare is a Scam2013 Rand ReportWorkplace Wellness Produces No Savings\Workplace Wellbeing Is a ScamEmployers should disband employee weight control programsUsing Incentives in Workplace Wellness ProgramsCoerced into HealthCurrent Trends in Reducing Cardiovascular Risk Factors in the USThe effectiveness of worksite nutrition and physical activity interventions for controlling employee overweightManaging Manifest Diseases, But Not Health Risks, Saved PepsiCo Money Over Seven YearsThe Dubious Empirical and Legal Foundations of Workplace Wellness ProgramsToward A Critical Theory of Corporate WellnessThe development and growth of employer-provided health insuranceThe Ideological Construction Of RiskWellness Incentives In The WorkplaceA Fatter Butt Equals a Skinnier WalletThe Outcomes, Economics, and Ethics of the Workplace Wellness IndustryWhat’s Bad about Wellness? Support the show

Oh fuck I gotta have a catchphrase huh? Oh for first time doing this. It's been a minute. Uh, 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. Question mark. That was a very direct one. I know your thoughts on this matter.

This is one where I am not coming in fresh. And it's one where I have strong feelings already. And I'm looking forward to having those feelings fed. I am Michael Hobbs. I'm Aubrey Gordon. If you would like to support the show, you can do that at patreon.com slash maintenance phase, or you can buy t-shirts, mugs, tote bags, masks, all kinds of stuff at T-Public. 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 podcasts, 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? I interrupted your rant to make you talk about logistics. And I even got back to it.

I was like, oh right, housekeeping. Yeah. Bathrooms are over here. Yeah. Put your pronouns on your name tag, that's wrong. What are your thoughts on workplace wellness, are we? 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 specific health and wellness metrics. And I was talking to a friend of mine who works in like a municipal government. One of her people who sort of works in her department came to her and was like, hey, I did our workplace wellness thing. And like I have an eating disorder and starting the day with getting weighed was like not my favorite.

Yeah, doing it at work. Right. Getting weighed at work. In front of your co-workers in a non-hip-a sort of setting, right, like I think it's worth questioning, why on earth this is the job of an employer to do? Oh my god, you're spoiling something that I was saving for like the last five minutes of this.

But like, yeah. It just feels like a real boundaryless mess of a system. And it like a real boundaryless mess of a system. And it's a real boundaryless mess of a system that has just permeated almost every major workplace that I'm aware of. Dude, 92% of employers in the United States have some form of workplace wellness programs. Shut the fuck up, are you kidding me? It's somewhere between like a four billion and a ten billion dollar industry.

Holy shit! What is wild to me is that workplace wellness programs have been around four decades, we will get into it, and there is no fixed definition of what workplace wellness actually means. Oh, get fucked. So this is a like natural foods thing. Yeah, so exactly. So like a lot of the articles that you read, they're like,

uh, some employers say like, yes, we have a workplace wellness program, but what they mean by that is that there's like a poster in the break room being like eat five fruits and vegetables. Uh-huh. And then other employers have these like really comprehensive, you get this incentive and there's this BMI bonus and there's this discount on your, and there's this discount on your health insurance, like really, really hardcore programs, but they're both labeled as workplace wellness. Yeah, the two that I remember most clearly and feel like 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. And I believe it was visible on the card too. So other employees could actually, like I think it would come up at the register to be like, oh, this person gets 15% off. The fucking barf.

Yeah, it's really barf. And the other was a brand of chocolate that I have otherwise enjoyed in my life. Tony's chocolate lonely 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. It's also discriminates against people like me who are trying to get huge, bro.

What about the dudes who are going for gains, bro? I know. What about the skinny shaming throughout our society? What about that? No one wants to talk about that. Yeah, nailed it. So 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 like completely fucking baffling. You know, they do have workplace wellness programs, even in other countries and other countries where they have more socialized medicine. Like 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 like, this is most Americans. 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, that's a lot of that legal compliance anyway. And sometimes you see histories of this that will say like the 40 hour work week is a workplace wellness program. Oh, Christ, are you kidding me? Like, no, that's, I mean, 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 kind of has to be something above and beyond like what you have to do as an employer or just something you're, you're only doing explicitly to get more productivity out of your workers. So like, that's what we're talking about, is like this extra stuff. And we're also not talking about, you have a boss who won't shut up about their diet, or you have a coworker 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. Yes. And when we talk about workplace wellness programs, it's a mix of good, neutral, and extremely bad things. Interesting. 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 gonna be like a fun freewheeling episode.

That's wrong. You thought you were gonna do something laid back and you fell out of a real rabbit hole. I was like, oh, that's gonna be a cute one. No, it's not cute. 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 the like 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.

So a lot of employers will provide free flu shots. Oh great. I don't love that being provided at an employer, but also like more people getting vaccinated against the flu is a good thing. I feel like, I don't know. It continues this sort of like insidious sort of thing of like your employer is kind of your healthcare provider.

Exactly. You know what I mean? So it's like blurring some lines. And also, I think the number one reason, certainly that people I know don't get a flu shot is just the inconvenience. We also heard from listeners whose employers started giving them more time off or kind of personal days.

Like one listener said that her workplace gives you like Friday afternoons off, like no questions asked. If you just like need to take some time for yourself. So like, cool. That's great. The last example of a good one that I have is a lot of employers also try to have healthier

food and the cafeteria. Having an option for people that has more vegetables in it or whatever, that seems fine to me. Like, great. Sure. But 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. It's the kind of thing that like if my employer

didn't offer that, I wouldn't ask for it, but also like sure. Yeah, I would also accept an employee discount for a Netflix membership. You know what I mean? Like, sure, you would give me discounts on stuff. Sure, sure, sure, sure. Some people said that their workplace would like 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 parista, and there was no room in the back. So they would just get a massage like in the cafe in front of all the customers. Shut the fuck up.

But I guess the customers would be like, I'm next, she's like, no. Yeah, I'm sure. 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? Great.

And then a lot of employers do things where like, they'll have a bowl of fruit at their reception desk. They'll send out a weekly health tip to employees. They seem pretty dumb to me, but also they seem harmless. And you can say that they're entrenching this paradigm and we'll get into it. But also the amount of 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 like fairly low on that ladder to me. I think listen, it's hard for me to talk about workplace wellness programs without grading on a real sharp curve. Yeah. Yeah. Like of course, on its face, a lot of these are things that I don't think really have an appropriate place in the workplace. And if we had better healthcare systems, none of this would be in the workplace to begin with. Exactly. And we would think of this as a weird thing. Well, this brings us to like the bad stuff.

Yeah, tell me. The main one is, yes, these financial incentives. That essentially if you meet certain health, quote unquote, parameters, you pay less for your insurance premiums. And oftentimes this is done in like 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. So it's like that sort of stuff where we're bringing in like extremely personal health information and this whole fucking weight paradigm basically into your relationship with your employer. And in some cases, you're like direct boss. Some people described having these like 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 missed one of your wellness appointments. Jesus fucking Christ. Wildly inappropriate. The boundarylessness of all of this is exactly. Fucking staggering. Like, think about how much you hate to answer

to your fucking mom about your body 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. I'm trying to think of the people I want involved in my relationship with my body the least.

Yeah. Like my boss and my employer. Yeah, yeah, exactly. Another really common one is Fitbit challenges or Fitbit metrics. So the idea is if you get 10,000 steps, you get a discount off of your health insurance, which like on the surface at first glance,

I can see how that sounds kind of like fun. Right. We're all gonna try to move more or whatever, but first of all, it's effectively a form of surveillance. Yeah. It's your But first of all, it's effectively a form of surveillance. Right? It's your activities outside of work, now playing into the way that you're assistant work. And also, a huge number of people cannot participate

in these challenges, right? 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. You're basically creating something that's like, oh, it's gonna be fun, we're gonna 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. There's also, 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. Which is also like a specific favorite of yours is the take the stairs. Take the stairs, dude. Like the idea that like if fat people took the stairs up to flights of stairs or whatever every day,

that suddenly we would not be fat people anymore. Exactly. Get the fuck out of here. It also just makes you super conscious of if you're a fat person at work, of your fatness, like other people, you know, you're all waiting for the elevator together. Right? And it's like, oh, I'm gonna see you in the future, I'm gonna take on the stairs.

Like it just, all this does is drive bullying and drive a culture at work of everyone like assessing each other's bodies and like health behaviors. Absa-fucking-lootly. And like, 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. Do you wanna hear the worst surveillance category of workplace violence bullshit that we got? Okay.

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 checkup, et cetera, pretty benign.

Until they introduced a forum where you could post photos of coworkers you caught being unhealthy and tag them in it. Shut the fuck up. That's right. They built in a public shaming feature with no way for the person you took a photo of to opt out. Okay, guys.

So, guys, I am gonna start throwing up, crying, and punching. I need the address of this building so that I can burn it down. That's turning everywhere into fucking eight champs. So, we're gonna circle back to the worst of workplace wellness and like the myriad reasons why it's bad. But we have to go through the history. Basically, as long as we've had workplaces,

we've had weird wellness efforts, bi-bosses, imposing them on their employees. Wait, really? Yeah, so Milton Hershey, the guy like the Hershey's chocolate guy, had a leisure park connected to like the chocolate factory where he expected employees to like go and do calisthenics during the day. Pilates before Pilates, calisthenics, yeah.

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. That sounds good to me. That's one of the good ones. I go on a little horse ride. But then I don't know if these actually count as workplace wellness programs because they're basically companies that have like too much profit.

And founders that have these like eugenics adjacent ideas about hiring like the right kinds of workers. Uh huh. 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, right? The idea is that if somebody's drinking, they're probably showing up late, and the smokers, you don't want people taking smoke breaks. Yeah.

And 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. Right. But 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 like wartime stuff out. So employers started offering health benefits as basically a way of attracting workers, right? Because we can't pay you more, but we can get you free health insurance. Once all of this kind of 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. And 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. That's fascinating. And feels like continued adaptation to, we're going to let capitalism run our health care system. Yeah. We start bargaining for this in employer contracts when you don't see any path to any other way to get health care and health insurance.

Profits in health. What did go wrong? Yeah. Boom. 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%. Wow.

I read a bunch of papers about why healthcare spending exploded in the 70s and 80s, and it seems to be a combination of the population getting older, much more access to healthcare services, like 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 are spending way more money on Healthcare and employers were starting to get really nervous in the 70s and 80s like hmm. This is 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 from 1979. I think I have seen this clip. Is it the Dan Rather one?

Yes, where he's like, what is wellness? Yes. Dude, it's such a fascinating artifact. Oh my God. It's so fucking good. I love it so much. It's great. They're like, they call it self-care.

Yeah! It's incredible! Okay. Okay, here it is. 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 were 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.

I had been in an 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 red ballpark figure of about $35,000 over the last nine years in medical care. Traditional medical care. Yes, and had achieved nothing. 152.3. 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. Doctors told him it was due to stress in his work. But any test or X-ray doctors administered to Julio proved negative. Like Theresa, Julio says he didn't find relief until he entered a program called wellness. Is what you're into a substitute practice of medicine? No, absolutely not. It is an adjunct too and quite different from the practice of medicine.

We don't treat diagnosis or prescribe. Our role is to help the person discover why they're sick. 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. He is a tone yes lower your morning. You just raised your hand temperature one degree. 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. Mike, when did you join self-care? Haha! Started caring for myself. This video has the tone of my dad repeating back to my nephew. What my nephew has just told him about Pokemon evolutions. All right, so uh, Charmander becomes Charzar? Uncertain, but like emotionally invested, like here for you, but not sure about all this, you know? Also how I conceive of heterosexual intercourse.

Like, this seems important, but I don't know how it works. It's really fascinating to me that like, part of the reason that this like, 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 like wrap their arms around and feel cared for.

I also love that it's this perfect distillation of where we are with wellness now, where it's like, it starts with a good concept of like health is obviously something more than just like the absence of disease, like you want to feel good as a person. And also, here's this quack shit that's going to like measure the quote unquote tension in your body and it has like a bio in the name So you think it's scientific. Boy oh boy. Oh boy. But I mean this this shift is something that we've talked about on the show before And I think we're gonna 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 you know 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, right? And we also get this sense that what you are doing on a day-to-day level affects how healthy you are. And this really becomes like the dominant paradigm of health. 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, right? 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. And if you did, then you wouldn'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. And if you did, then you wouldn't be sick or you wouldn't be blah, blah, blah. Right, like it is extraordinarily ruthless kind of logic that underpins a lot of this.

Well, I think a lot of the precepts of it are true, right? So, you know, heart disease and cancer are to number one and number two killers of Americans. So like, obviously, we should be taking those things seriously, right? And, like, of course, our lifestyles affect our health, right? Like, 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. Yeah.

The fact that your lifestyle affects your risk for disease is like pretty unobjectionable, but eventually it became that your lifestyle is the only thing that affects your risk for disease. Yeah, we then start getting the reverse understanding, which is well then everybody who's sick must have done something to deserve it. 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? 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 it feels really good to you and what it allows you to believe about yourself and the world and your place in it. Right? Well, also,

this stuff almost immediately gets taken up by corporations in various ways. Yeah. In the first place. Bullshit skin care 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. 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 like journal articles that have debunked the shit out of it. And they're like 40 to 70 years old. I know. You're like, oh man, we've known this whole time.

I know, you're like 10 minutes after it happens. Somebody's like, this seems bad. And then we have to make a podcast 40 years later. All right, here's this. 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 multi-pronged 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 work site health promotion. Thus, work site wellness programs with their goal of keeping employees healthy and reducing medical care utilization are a part of this cost containment strategy. Right, it's just about money.

Very openly, like corporate executives were saying this at the time. It's really amazing to me what a fucking hot potato healthcare costs are. I know. Everyone's doing the thing where you like put your finger on your nose and go not it. Yeah.

Like first the state did it and then employers are now like, wait a minute, me too. 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. Yeah. Right, because they like having this as a benefit that they can offer to recruit employees.

So it's like, you realize this isn't helping you either, right? Like this sucks for literally everyone and it just like keeps getting kicked down the road. Yeah. So the next like 40 years are just more and more expansion and entrenchment of this concept. So in 1979, we get a Surgeon Generals 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 and Johnson is one of the first ones in 1979. They launched this huge workplace wellness program that like they've published a number of academic articles over the years about like 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 80s and up until the 2000s showing that the saves money for employers. So one of the early ones finds that companies save a dollar and 43 cents for every dollar that they spend on workplace wellness. 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 kind of 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. Well, but also $11 for every $1 is some real 400,000 Americans die of obesity every year, kind of math where you're like, how? Aubrey, don't imply that we're gonna deep bunk these numbers later.

I don't, I'm delivered. That you assume that I'm giving you some numbers, but leaving out relevant concepts. Wow. I can't believe that you would question an 11 to 1 return on investment. The betrayal, my own co-host. My own co-host. At 2,brei.

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. So that's fun. So the 1990 Americans with Disabilities Act includes a specific carve-out for workplace wellness programs. Get the fuck out of here. 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. Nope.

So it's like, as long as it's voluntary, it's chill. As long as you're opting in to getting paid for if you're not disabled, right, like, I'm just like, this is fucked. So that's 1990. In 1996, we get HIPAA, which is mostly known now as like 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. Carbage! 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, right? 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, right? You're basically co-worsing people into this

with like, they have to pay more money. So HIPAA says 20%. If health insurance is costing people 500 bucks a month, you can give them an incentive of up to $100 a month. Gotcha. That way it's voluntary because it's not that much money or at least that's the idea. Yeah, although, like, listen, we live in a country

where in some cases, your health care costs can rival your housing costs, right? Oh, yeah. 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? Like, the idea that, that like $100 a month is a negligible amount of money, is like bonkers.

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? Ah, but non-disabled people pay less for this. That's fine. Somehow, but it's like, I don't see how they're different, right? But non-disabled people pay less for this. That's fine. Somehow, but it's like, I don't see how they're different, right? Ultimately, at the end of the day, disabled people are paying 500 bucks

a month and non-disabled people are paying 400 bucks a month. Yeah. Whatever you call that, there's a material reality that is being created here. Yes, absolutely. Another thing, this is Yes, absolutely. Another thing, this is foreshadowing alert, Awoga. TIPPA 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. Jesus Christ. There's a long pause there. I was like, did Aubrey die? Did I kill Aubrey?

No, I'm just tired. So like, I used to work on this kind of stuff, right? 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? Yeah, yeah. You pass a law, people think that's the end of the work,

that's the start of the work. Wait, Aubrey, what? What, what, what? What, Aubrey. Am I skipping ahead? They do actually revisit this. So you're about to be very happy. Oh, okay. They do revisit this, but they make it worse.

So I have, I have an excerpt for you. Oh, send me an excerpt. So context, HIPAA passes in 1996, fast forward. Obama is elected in 2008, and one of his major campaign promises was reforming the health care system. So throughout 2009, 2010, there's, of course, this huge debate of what is health care 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 Healthcare 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." Quote, our plan utilizes the 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. Safeways Healthy Measures program is completely voluntary and currently covers 74% of the insured non-union workforce. Not foreshadowing. 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.

But you can take the test again once you're healthy. Congratulations. You were diabetic this time, but maybe not next time. Have you tried biofeedback? The numbers speak for themselves. this time, but maybe not next time. Have you tried biofeedback? The numbers speak for themselves. Our obesity and smoking rates are roughly 70% of the national average, and our health care costs for four years have held constant. Today, we are constrained by current laws from increasing these incentives. We, 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, right? But those costs haven't gone down nationally, so that just means you're employing more people who already had low healthcare costs.

Uh, stop spoiling the GPS system. Stop knowing things. Sorry, sorry, sorry. This is like 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. We can only offer 20% incentives.

That's not enough. We got to be able to reward. For larger ones. Right, and 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 faults of fat people and disabled people, right? Yes, this has totally been memory hole, but like this was a huge part of the debate over Obamacare in 2009, 2010. Really? 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 do to government regulations. It's really amazing to me that all of them turned into like Mrs. Lovejoy from The Simpsons, and they all started going, won't someone please think of the Safeway CEO? Like a lot of them do it. Thank God I'm in due. I mean, this became like a huge deal,

like the Safeway CEO basically did a like tour of Capitol Hill and met with a bunch of legislators, including Obama, and in 2010, when they were debating the version of the Affordable Care Act that they had, they included something called the Safeway Amendment. Shut the fuck up. 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. Holy shit. So basically, this past, this is in the Affordable Care Act. I'm curious about in your research of this, did you find much in the way of critiques of not how workplace wellness programs sort of are implemented or regulated, but critiques of the existence of or the structure of workplace wellness programs? Not until later. What was really frustrating in the reading

for this episode was how much the cost logic seemed to dominate everything. How much return do you get for like this dollar of investment? There's a million of these and there's a million estimates of this. But qualitative research of what are these programs and what does it feel like? What are some of maybe the unintended harms of these? Almost nothing. 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.

And 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. Right, so people instead of having a conversation that is in any way grounded in anyone's humanity or in anyone's like 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. So before we debunk everything that we just went over, we're gonna talk a little bit 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 like years. Good.

Quote, 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! Yeah! Fucking fix it for Terry! So you basically have somebody who's like, she has diabetes and she's paying more. This is exactly the scenario that three different laws now have sought to avoid. Right, so like 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. Why? Get the fuck out of here. There's also an interesting sentence here

where it says Terry's employer refused to exempt her from the BMI target. So in HIPPA, it says that if you're not able to participate in these wellness programs, you get an exemption, right? So 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, employer 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 quote unquote real reason. Jesus. This is an excerpt from a very good legal analysis of all three of these laws that I read

and how they relate to workplace wellness programs. And you can like 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. Good. After all, the point of wellness programs is to discriminate. Yeah.

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. Yeah. 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.

That quote, the point of these programs is to discriminate, is a real say it louder for the people in the fucking back. That's what they do. That is what they are here to do. So the last, like, extra part emails that I want to read, there's Aubrey, there's so much here. There's like so much, they were going to cover it 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. Yeah. The number of workplace biggest losers, competitions that are out there, make me want to like just barf myself to death. I don't even know.

I'm so so bad. Repulsed. This is just one of the emails that we got. 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 1,000% expected that I would participate. I did not, because eating disorder and also fuck all of that. 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 I got for eating normal amounts of food led me to never again eating anything in front of coworkers still 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. Do not do this to people in the workplace. Not eating in front of people is such a deep, fat people thing. Yeah. And it is a direct result of how other people treat you. And 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? 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. Like that's fucking horrible. I'm so sorry to this listener.

I'm breaking my own rule and reading one more because I can't help myself. Great good. This is a really awful one. I feel like it's such a like perfect example of why these are so bad. A couple 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 posted a food diary slash 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, I have IBS and I can't do this because I have to go to the bathroom a lot.

But that's not something you necessarily want to disclose to your manager who's in charge of promotions and shit. Like 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. 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. Exactly. Listen, I understand that this is not the legal definition, but like I would interpret on an emotional personal level, all of this shit as an extraordinarily hostile workplace.

Oh, super duper, yeah. And it's this hostility that's like, what's your problem? It's fun. Yeah. It puts you in this position where you have to be like, this isn't fun for me. Totally. It feels like there's something about that. Like, 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 gonna drink. Right, right, right. People go, come on, loosen up, it's just one drink. Well, and I'm like, why are you so invested in overriding this person's own decision about how to relate to this situation? Yeah, yeah. 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 sort of 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, 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 like keep ignoring what you're directly asking me not to do and do it anyway 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 At least in fairness they might be entirely useless. Completely useless at best.

So the first thing we need to debunk of everything we've gone over in the history of this is that Safeway was fucking lying. Yeah, there we go. Yeah. So it turns out that Safeway's costs did in fact, decrease. They decreased in 2006, three years before they launched their workplace wellness program because they shifted a bunch of the costs to employees.

Yep, they did what every major employer was doing at that time, right, which is breaking it to their employees that they were going to have to chip in like hundreds of dollars a month for something that was previously free or way lower cost. So it's like that they raise your deductible, they have different yearly limits. Like a lot of employers do this in like this sneaky way.

Also, when they said in that excerpt that it was like our non-union health insurance employees, it turned out to be something like 2% of their workforce. Right, non-union either means they have such a low level of hours that they're not represented. Right. Or it means they're fucking management. And either way, that's not a representative picture.

So just complete bullshit. The most amazing and frustrating thing about this is that the Washington Post investigation that reveals all of this and like interviews some like sub CEO person at Safeway who's like, oh yeah, we were lying. Just like so long. It's like, oh yeah. When we said that we were lying basically, all of that came out months before the Affordable Care Act was passed.

So like 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 like meta-analyses whatever of like 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. 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 months, although none of the results were significant. Great. I love the little like, hey guys, here are all the amazing results. None of them are significant. Right, like, hmm. 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 like, you know, the average American, it's something like 175 pounds. So this is a 2% weight loss. Good, good, good, good, good. Also, none of the money saving like $3 for every dollar you spend. None of that should 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 health care than workers without health risks. I can grow.

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. Good. In 2018, there's yet another health affairs meta-analysis that says we conclude that these programs increase rather than decrease employer spending on health care with no net health benefit.

The programs also cause overutilization of screening and checkups, put undue stress on employees, and incentivize unhealthy forms of weight loss. It's not just discriminatory, it's also ineffective. 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 like workplace bonus program, most of them show that it works. Like 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. Yeah. 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 quote unquote healthy to begin with. So like someone like me, like I already go to the gym. If my workplace says like, oh, we're gonna 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. Totally, but it's like, I'm somebody who already has your gym membership, tax free, I'd be like, yeah, sure. Totally. But it's like, I'm somebody who already has a gym membership. 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. Like 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. And on top of that, if you also had any kind of mobility issues, if you also had any 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 work for you. 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.

Because these are people without chronic illnesses and disabilities and stuff. They're like the quote unquote 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 like doesn't fit the format. All that well, but I just wanted to talk about it

with you because it's hella funny great 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 So there's a couple of actually like genuinely well-designed studies that are 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 like a pretty good design. And 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 for use. So the measure ball, the stuff that we can measure.

Right, so what it does do is make more people tell us what we told them we wanted to hear. Exactly. And we would pay them if they told us those things. But then this is something we come across all the fucking time on this podcast. These studies will say, like, well, it affected these, like, totally bullshit indicators, and it didn't affect these real indicators and what we set out to do. So the findings are mixed.

Yeah. Good. indicators and what we set out to do. So the findings are mixed. Yeah, good, good. Great, it's like, 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 precede improvements in other outcomes, findings could be consistent with future improvements in health or reductions in spending.

Listen, man, the checks in the mail just hasn't gotten to you yet. Don't worry about it. But then, okay, listen to this. I, this is maybe one too many examples, but I like to have it on the record. So, this is the conclusion of a huge like also fairly well-designed randomized control trial at the University of Illinois that That was called I thrive and because it's like the mid-2000s. It's like a little I like iPod

like So the study finds essentially no benefit other than this like 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 seem to value the 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, if you want to do something that works. Well, I also like that it's like, well, employees report X, Y and Z things.

And I'm like, yeah, employees report liking not having to spend extra hundreds of dollars every year. 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, you know, if you're looking for something, then a manager's health care cost 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? 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.

This feels like that as a logic model for policymaking. We're just like every possible justification for these programs has been pulled away from them, right? Every possible support that these could have had have been taken away and now they're just like somehow levitating and mitigating. Exactly. They're still there. But wait, there's more.

Oh, no, Mike. 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. Uh-huh. Workplace wellness is a like wildly grifty sector.

Yeah. Because the HIPAA law refused to impose any standards on the industry, right? These don't have to be backed up by science. So there's an entire sector that is like workplace wellness consultants, right? These are usually done through third party firms. And there's essentially no regulation of the content of these perfect. So a lot of these firms are basically like used car salesmanship. They bring like 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. Like in your body. Hey man, you gotta flush out your boiler every week. Otherwise you're gonna start circulating rusty water through there. Wow. 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, right? So the idea is you get an incentive for like going and having an annual physical. And then that allows you to identify things before they become big problems. As a principal, this sounds totally uncontroversial, right? Go get a health screening every year. Great.

The problem is there's no actual standards for what constitutes an annual physical, even within the medical field. This isn't very well defined. And 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 like having their kidneys removed because they tested positive for some sort of like kidney, blood disease, something, something, but it's just a false positive.

God, this is like your workplace wellness program as designed by Elizabeth Holmes. And I don't wanna 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 really see a doctor. And if you're somebody who hasn't seen a doctor in a while,

right, so a lot of poor people in America do not have regular contact with the healthcare system. Yeah. But basically if there's a reason to go to the doctor, like go to the doctor, right? But what we're talking about in these workplace wellness programs is quote unquote healthy people going to see a doctor every single year.

And the more people do that, the more they increase their chances of like testing positive for something. So 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, right? So there's an Nebraska program that says we prevented, there was like 400 cases of colon cancer. And like, oh, look, look, we're prolonging the life of your employees and look how great this is.

But later on, it turns out that the firm was just faking their data. Shut the fuck up. The problem with the US health care system is because it's a fee for service model, people only get paid if they're providing a service. So oftentimes, people go in and the doctors like, oh, you need to come back next week for this thing.

And we're going to screen you for this just in case. And some of what gets called over treatment in America is actually treatment for people. And this is a fucked up and ableist narrative. But also, there is a lot of over treatment in the US health care 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 like might not actually be necessary. Well, and that also seems less like an issue of over-treatment and more like an issue of bad treatment from people who should have to have some kind of qualification. Right, it shouldn't be going through the like beware of dirty water people. Those people should not be involved. Yeah, it shouldn't be going through the like beware of dirty water people. Those people should not be involved. Yeah, that's right. 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. And what happened is we started

conflating the risk factors for causes. Yes. Well, you hear a lot is that obesity is a risk factor for heart disease, right? 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 health care 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, you know, 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. Well, and to this point about over-treat treatment slash bad treatment, right? 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. Also, the costs of treatment of fat people are also kind of the costs of our assumptions

about what being fat means about your health, right? And also, it also doesn't acknowledge the actual reasons that are driving US healthcare spending. So a lot of healthcare spending is actually driven by hospitalizations. And people have gone through and looked at these kind of chronic risk factors and there's a study in 2012 that looked at cholesterol, blood pressure, etc.

And all of these kind of these factors that we associate with chronic illness, they only account for about 20% of healthcare spending. And it also seems that, you know, sort of 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 quote unquote 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 gotta be fat people and disabled people. Get them out of here. So I wanna end with the one area where this does work and then a happy ending. Tell me. The only aspect of workplace wellness

that I could find that's effective appears to be these smoking cessation programs. Oh, interesting. They're not like the most effective, mostly because quitting smoking is just really hard and the relapse rates are high. But like, yeah, people who are enrolled in smoking cessation programs have higher rates of quitting.

But 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 like workplace quit smoking programs. They're just quit smoking programs. Yeah. All of the stuff about, you know, the posters and 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 health care, hospitals could just provide it to people who needed it. 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? Well, and 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 health care and

access to treatment for every part of that population. We as a country keep refusing that very clear lesson, like time and time and time again. People seem weirdly surprised that a health intervention designed to only reach thin rich people with office jobs. 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. Oh, what a twist.

Basically, people fucking hate these programs. And there's a massive backlash. A huge number of the people who wrote into us did tiny acts of resistance, a lot of people, numerous people put their weight as like 50 pounds. I'm not that hard. It's well-missed program time. They're like, fuck you, my BMI is like,

nowhere near any of your business. I am 5, 10, 50 pounds, fuck you. Yeah, yeah, yeah, yeah, good, good job. And then 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 to like nobody lost weight on a weight loss program.

There's an academic article called, employers should disband employee weight control programs. Good. Like, people are finally coming to the obvious conclusion from years of data that just like these 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. 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.

Exactly. If they work that as well. This is not a case of like, oh, we've really been bamboozled into thinking that this thing is okay. No, everyone's been saying the quiet part loud this entire time. Right. Yeah, I mean, I think I'm so glad to hear that there is some kind of emerging like, oh, wait a minute, we should stop this. But Aubrey, how else are we gonna know about all the dirty water? I don't want to do it. You're so stupid. You're so stupid. Thank you.