Abstract
In the U.S., ‘employee wellness’ programs are increasingly attached to employer-provided health insurance. These programs attempt to nudge employees, sometimes quite forcefully, into healthy behaviors such as smoking cessation and exercise routines. Despite being widely promoted as saving on healthcare costs, numerous studies undermine this rationale. After documenting the programs’ failure to deliver a positive return on investment, we analyze them as instead providing an opportunity for employers to exercise increasing control over their employees. Based on human capital theory and neoliberal models of subjectivity that emphasize personal control and responsibility, these programs treat wellness as a lifestyle that employees must be cajoled into adopting, extending the workplace not just into the home but into the bodies of workers, and entrenching the view that one belongs to one’s workplace. At the same time, their selective endorsement of health programs (many scientifically unsupported) produce a social truth of wellness framed as fitness for work. We conclude by arguing that the public health initiatives occluded by the private sector’s promotion of wellness programs would be a much better investment of resources.
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Notes
This paper will assess employee wellness programs in the context of the United States. Comparison with other countries is important, but beyond the scope of this paper. The U.S. is differentiated by its employer-based healthcare system, and the consequent financial burden that unhealthy employees thus place on employers. For an initial consideration of wellness more generally, with a focus on the UK, see Chris Till (in press). Till emphasizes that wellness programs are often conceived as a form of profit-enhancing “philanthrocapitalism” (and thus under the umbrella of corporate social responsibility), whereby what is deemed good for the employer (in this case, the habituation of employees to high levels of activity) is made to coincide with social health considerations, insofar as those involve individual responsibilization.
Some aspects of the legal discussion here may be dated or obsolete if President Trump and the Republican Congress elected in 2016 make major changes to health law policy. However, the underlying dynamics of moral hazard and risk selection will persist. The GOP’s anticipated reduction in federal funding for health care will raise the appeal of ostensibly cost-saving wellness programs. And even if the ACA is repealed in its entirety (an unlikely event as long as Senate filibuster rules remain), wellness programs were authorized by prior legislation, and would persist.
These are the dominant form of wellness program, and are the topic of this piece; they include programs that require a certain amount of physical activity, a certain level of weight loss, smoking cessation, or other standards.
The plan does not appear to be doing anything more than data collection at this time, and employees can even indicate that they do not know their blood sugar level or when it was last measured. Also, the data are not verified except by the employee’s attestation that it is accurate. In any case, the plan is accumulating a lot of data, as it serves well over half a million employees.
Health economists now disagree: the outlier status of US health spending was, and still is, a result of higher prices, not more utilization (Pasquale, 2014c). To be fair to employers, this was also the easiest factor for them to exert any control over; however, repeated business efforts to scuttle universal health care should temper any sympathy here.
The point is the indirect regulation of behavior: the goal is to, for example, nudge people toward certain preference orderings, and not push them directly into one course of action or another. This is often paraphrased from a later interview as the “conduct of conduct” (Foucault, 1982, p. 222; see also Foucault, 2008, p. 186).
Thus economic analysis extends into the social sphere (Foucault, 2008), resulting in the “economization” (Brown, 2015) or “financialization” (Harvey, 2005) of all phenomena. For the general case against neoliberalism, see especially Brown (2015). For the somewhat loose fit between neoclassical economic theory and neoliberal policy recommendations, see Mirowski (2013). The literature debating what exactly neoliberalism entails is, of course, vast; here we only emphasize aspects of it that are relatively non-controversial.
Although we will not pursue the point here, Becker also said that human capital theory predicts that health spending will ultimately worsen socio-economic divides: “People who have better life expectancies also have higher earnings and greater education, save a larger fraction of their permanent incomes, have ‘better’ habits, and also have greater conditional life expectancies, given that they reach any age. So characteristics like earnings, habits, discount rates, and saving do not offset inequality in life expectancy, but reinforce that inequality to contribute to a still widen[ing] inequality in overall welfare” (2007, p. 393).
For other examples of neoliberal subjectification, see, e.g., Binkley (2009) (on literature about “two dads”); Binkley (2014) (on positive psychology); Cooper (2012) (on workplace transformations); Hamann (2009) (on the general production of homo economicus); Hull (2015) (arguing that notice-and-consent privacy policies primarily serve to teach that privacy is a tradable commodity); Langley (2007) (on financialization of retirement plans); McMahon (2015) (on the role of behavioral economics); Mirowski (2011) (on university science research); Pongratz (2006) (on the role of formal education, focusing on Germany); Read (2009) (on the general production of homo economicus); Simon (2002) (on the rise of extreme sports); Strandburg (2005) (on university technology transfer programs); Winnubst (2015) (on cultural figures of ‘coolness’ and ‘diversity’); and Winslow (2015) (on restructuring in higher education).
The executive then touts “consumer directed health plans,” which are supposed to cause employees to shop around and make better healthcare decisions, since they are allocated a certain amount of money to spend, rather than access to insurance. These programs are ethically objectionable and likely to be very burdensome on the chronically ill (Jost, 2007).
A full theoretical analysis of neoliberal selfhood is beyond the scope of this paper. Some initial thoughts can be found in Till (in press). Till grounds his argument – and here we agree that this is a fruitful literature – in Italian autonomist political theory (Franco Berardi and Maurizio Lazzarato) and Boltanski and Chiapello’s New Spirit of Capitalism. What emerges in all of these sources is the importance to modern capital of regulating affect. Hence, for example, the importance of efforts at nudging employees to be happy.
Of course, this attachment is purely a one-way street: employers feel no compulsion to retain employees, offer long-term contracts, or otherwise scale back from the insecurities generated by at-will employment and the decline of collective bargaining. But employees are taught that work, and preparation for work, should structure their entire lives.
For criticism of that view, see (in addition to Gillespie), for example, Boyd and Crawford (2012) (noting both the lack of objectivity and the tendency to produce spurious correlations); Crawford (2016) (showing how algorithms are embedded in concrete social struggles); Esposti (2014) (noting the situatedness of algorithmic knowledge); French (2014) (showing gaps and irregularities in the context of health data); Kitchin (2014) (debunking the positivism behind much big data enthusiasm); Rieder and Simon (2016) (situating big data in the social trust in quantification); and Ruppert (2012) (emphasizing the complexity of contexts in which big data is used).
While powerful as tools to reinforce addictive behavior (Schüll, 2016), neither nudges nor variable reward schedules may be optimal solutions to the problems they have caused.
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Hull, G., Pasquale, F. Toward a critical theory of corporate wellness. BioSocieties 13, 190–212 (2018). https://doi.org/10.1057/s41292-017-0064-1
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DOI: https://doi.org/10.1057/s41292-017-0064-1