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Counterpoint: Response to Dr. Cawley
July 10, 2014 10:00 AM
By Morgan Downey, J.D., Editor and Publisher of the Downey Obesity Report
A few weeks ago, we presented both sides of a discussion of the Affordable Care Act, where premiums can be adjusted to create incentives for individuals to engage in healthier behaviors including weight loss. Professor John Cawley followed up last week with his counterpoint to Morgan Downey's position paper. In this final counterpoint, Downey presents his counter to Cawley's initial positional paper, The Affordable Care Act Permits Greater Financial Rewards for Weight Loss: A Good Idea in Principle, but Many Practical Concerns Remain.
Cawley and I agree that financial rewards have a mixed record. EWPs have not demonstrated sufficient return on investment and, at best, induce only short-term behavior change. We agree that the body mass index (BMI) is a poor criterion. It can be overinclusive of persons who may not develop expensive comorbidities for years, if ever, or who have high muscle tissue. Up to one-third of persons with obesity measured by BMI are metabolically normal. The BMI can be underinclusive as well. Persons with a normal BMI and a high percentage of body fat have high risk for cardiometabolic dysfunction.
I would respectfully disagree with Cawley on a few points. I would not recommend that the Affordable Care Act (ACA) should provide more flexibility for health plans in the design of EWPs. The legislative proposal to increase the size of the incentive/penalty permitted (from 20 percent to 30 percent of the health insurance premium) was enacted on the basis of claims of success from the then-CEO of Safeway Inc., which have never been substantiated. Studies to-date involved volunteers and those produced little weight loss. We have no experience with employees compelled to participate in such programs. Studies on the durability of weight loss in EWPs are lacking. We have no experience with EWPs that provide alternative routes to the reward and involve the employee's personal physician.
Read Morgan Downey's full counterpoint at WileyOnline.