Wellness and
Prevention in Health
Reform
Concerns with wellness plans and examples
of consumer-friendly prevention provisions
Claire McAndrew
Families USA
February 16, 2010
Wellness Plans Today

Individual market wellness
plans are not federally
regulated; some states
have passed relevant laws

Group market (workplace)
wellness plans are
regulated by HIPAA rules

Rules divide employer
wellness plans into two
groups:
Wellness Plans Today:
Employer Plan Design

Plans based on participation goals:
 Example: Employees who participate in a
nutrition seminar will have a lower deductible
for their health insurance
 Incentive size restriction: none
Wellness Plans Today:
Employer Plan Design

Plans based on health factors/ outcomes:


Example: An employer charges a higher
deductible to workers who do not have a BMI
under 35
Incentive size restriction: 20% of the value of total
health insurance premium (including the
employer’s and the worker’s share)

Average worker premium for ESI in 2009: $4,824
(Kaiser/HRET 2009 Annual Health Benefits Survey)

20%= $965
Concerns with wellness plans
today




Access to coverage and care: Surcharges could
make health coverage unaffordable altogether
Lack of evidence-base
Lack of comprehensive supports in programs
Inequities: may place a disproportionate burden on
individuals with low-incomes, racial and ethnic
minorities, and individuals with chronic health
problems or disabilities
Concerns with wellness plans
today

Privacy issues



Alternative standards
Verifying compliance/ measuring achievement
Lack of appeal rights
Wellness Plans and Health
Reform: Senate Bill

Increases allowable incentive from 20% of
premium value to 30%, with the option to go
up to 50%

This would increase allowable surcharges from
$965 to $1,447 for an average worker, with the
possibility of a $2,412 surcharge (using 2009
average values as an example)
Wellness Plans and Health
Reform: Senate Bill

Provides incentives for 10 states to start
incentive-based wellness plans in their
individual markets/ exchanges


Expands to more states in 2017 at the Secretary’s
discretion
Major concern: Bill language appears to allow
wellness surcharges to be tacked-on after
people receive premium credits, undermining
affordability protections
Wellness Plans and Health
Reform: Medicaid


Grants for states to do Medicaid wellness
programs
Protections




Evidence-based
Take into account unique needs of Medicaid population
Incentives cannot affect eligibility or benefits
Issue to watch
Wellness Plans and Health
Reform: House Bill


No change to incentive limit (20% for outcomebased plans still stands)
Grant program for small businesses to start wellness
plans, but only those that do NOT vary premiums or
cost-sharing


To receive grants, programs must also be comprehensive
and provide an array of supports
Note: Final Senate bill adopted some of these
provisions— created a small business grant
program with some standards, but doesn’t prohibit
insurance-linked incentives.
Wellness Plans and Health
Reform: Talking About It


House provisions reflect broader health
reform goals: evidence-based,
comprehensive supports for improving health
Senate provisions contradict broader goals of
health reform, which seek to eliminate:



Pre-existing condition and health status
discrimination
Unaffordable health coverage and care
Concerns with today’s plans still stand
Wellness and Prevention that
Works for Consumers: Senate Bill

Comprehensive coverage
for and increased access to
preventive and health
promotion services




Private Market: Essential
benefits package
Medicare: wellness visit, no
preventive cost-sharing
Medicaid: smoking cessation
for pregnant women
Grant program for states to
increase adult vaccination
rates; Medicare study of
beneficiary vaccine access
Wellness and Prevention that
Works for Consumers: Senate Bill

Targeted prevention and health
promotion efforts based on where people
spend their time:



Grants for school-based health centers
Grants to states, local governments, and
community organizations to implement
evidence-based, community prevention
activities
Specific grants for community health
prevention and health promotion activities
targeted to individuals ages 55-64,
including screenings and referrals
Wellness and Prevention that
Works for Consumers: Senate Bill

Support for a
preventive and public
health infrastructure


Creates a preventive
medicine and public
health training grant
program
Establishes a Community
Health Center fund to
increase investments in
centers
Wellness and Prevention that
Works for Consumers: Senate Bill

Public awareness and education





New fund for national prevention and health promotion
strategies
New campaign to make Americans aware of new
access to preventive services
Oral health prevention campaign
Breast cancer awareness campaign targeted at young
women
New national diabetes prevention campaign and CDC
National diabetes “report card”
Wellness and Prevention in
Health Reform: Takeaway
Wellness and prevention=
GOOD!
Underwriting and
insurance discrimination
disguised as wellness=
BAD!
Wellness and Prevention in
Health Reform: Resources
Families USA Talking Points: “Senate Amendment on Wellness
Program Surcharges Jeopardizes Access to Affordable
Coverage and Care”
http://www.familiesusa.org/assets/pdfs/wellnessamendment-in-senate-bill.pdf
Families USA Blog Post: “The Wellness Plan Discrimination
Loophole”
http://www.standupforhealthcare.org/blog/archives/the_well
ness_plan_discrimination_loophole/
HIPAA Rules on Wellness Plans: “Nondiscrimination and
Wellness Programs in Health Coverage in the Group Market;
Final Rules,’ Federal Register 71, no. 239 (December 13, 2006):
75014-75055.
http://www.dol.gov/ebsa/regs/fedreg/final/2006009557.htm