Health Care’s Brave New World of Compulsory Wellness: Ezra Klein

It treats Saudi sheiks — and funds itself, at least in part, through their grateful, post-operation donations — and is constantly toured by campaigning politicians looking to associate themselves with the best of American medicine.

But the clinic has a more interesting — and more consequential — story to tell right now, and it has nothing to do with providing health care to its patients and everything to do with curtailing health care for its workers.

With 40,000 employees, the clinic is the second-largest employer in Ohio. Like most employers, it struggles to contain health-care costs. But according to Michael Roizen, the clinic’s director of wellness, over the past seven years a series of reforms instituted by the clinic’s chief executive officer, Delos Cosgrove, slowed and then arrested the growth in employee health-care costs at the clinic. This year, inflation-adjusted spending might actually fall — an all but unprecedented achievement in employer-based insurance.

What happened? Health care costs rose 6 percent a year nationally. Yet there was no rationing of care or squeezing of providers at the clinic. The clinic’s employees simply got healthier. Whether that success is a model for American health care or a preview of a dystopian surveillance state is an open question.

Common Problems

Roizen says the initiative sprang from a single fact. According to the Centers for Disease Control and Prevention, 70 percent of all medical costs are related to smoking, physical inactivity, food choices and portion size, or stress. Cut smoking, increase physical activity, persuade people to make better dietary decisions, and help them manage their stress, and you can reduce health-care costs before an employee ever steps into a hospital.

But consider what that actually entails: Changing habits. Breaking addictions. Getting people to the gym. Who wants to hear about any of that from their employer?

The clinic, however, didn’t give employees a choice. “First thing we said was we had to make our institution toxin free,” Roizen said. “The biggest toxin we have in the U.S. is tobacco. So we began offering free tobacco-cessation programs to our employees. Then we banned smoking on campus. You can’t even smoke in the parking lot in your car. The first offense you get a warning, and the second you get fired. We fired two high- profile physicians who refused to quit. Then they knew we were serious.”

Food came next. The clinic took out almost every deep-fryer in the building. They removed sugared soda from every beverage case. They eliminated trans fats. On a tour of the campus, I noticed a long line outside a McDonald’s. My guide sighed. McDonald’s, he explained, had a long-term contract that predated Cosgrove’s wellness initiative. The clinic couldn’t throw them out — yet.

“We want to make it easy for you to do healthy things and hard for you to do unhealthy things,” Roizen said. “If you want a sugared drink, you have to go out of your way to bring it from home. We’re not going to provide it.”

That left fitness and stress relief. The first step was easy: Offer free fitness and stress-management classes. But the clinic still had to get its employees to attend. So they reversed the normal calculus. Usually, you have to pay to hit the gym or attend a yoga class. If you work for the Cleveland Clinic, you have to pay if you don’t.

“We raised the premiums for all employees,” Roizen said. But employees didn’t necessarily have to pay the increase. “If you’re doing a healthy program — attending Weight Watchers or Shape Up and Go — you get a rebate.”

Tracking Results

That left enforcement. The clinic tracks its employees’ blood pressure, lipids, blood sugar, weight and smoking habits. If any of these are what the clinic calls “abnormal,” a doctor must certify that the employee is taking steps to get them under control. Otherwise, no insurance rebate. The idea is to force employees to have regular conversations with their doctors about wellness. If they participate, they can lock in the rates they were paying two years ago. The savings amount to many thousands of dollars.

It appears to be working. Not only has the clinic cut its health-care costs, but its employees are also getting healthier in measurable ways. Workers have lost a collective 250,000 pounds since 2005. Their blood pressure is lower than it was three years ago. Smoking has declined from 15.4 percent of employees to 6.8 percent.

In one sense, the clinic has achieved the health policy ideal: cutting health-care costs by making people healthier. But consider how the clinic has done it — tying premiums to personal decisions, firing smokers, tracking employee metrics, eliminating popular sodas and foods from campus. By making it harder and more expensive for employees to be unhealthy, the clinic has radically overstepped the traditional, laissez-faire approach of employers to their workers’ personal habits.

It also opens the door to onerous forms of discrimination. The clinic no longer hires smokers. Will the obese eventually face similar hurdles? What about fans of fast food?

The experiment might work at a famed medical center where the CEO plausibly argues that aggressive leadership in health care is central to the institution’s mission. But would it work at General Motors? Caterpillar? Wal-Mart? Medicaid and Medicare?

Roizen thinks it can — and should. He estimates that an aggressive program could cut federal health spending by $300 billion to $600 billion a year. If he’s right, then simply instituting such wellness reforms could cut the federal deficit by far more than the Simpson-Bowles commission or the congressional supercommittee would.

Medicare Proposal

Roizen has even proposed legislation to create a Medicare pilot that sidesteps at least some of the concerns about government intrusion. Participation by Medicare recipients would be voluntary, with improved health leading to an increase in a participant’s Social Security check.

As Roizen notes, tough choices are inevitable over the next decade. The question is which ones we prefer to make. If we opt for Cleveland Clinic-style wellness programs, we won’t have to gut education, raise taxes or slash Medicare. And we’ll end up healthier. But in a country where proposed counseling sessions to discuss end-of-life options were denounced as “death panels,” are we really ready to let employers — much less the government — tell us to quit smoking, skip the junk food and lose weight?

(Ezra Klein is a Bloomberg View columnist. The opinions expressed are his own.)

To contact the writer on this story: Ezra Klein in Washington at wonkbook@gmail.com.

To contact the editor responsible for this story: Francis Wilkinson atfwilkinson1@bloomberg.net.

WHY is nearsightedness so common in the modern world? In the early 1970s, 25 percent of Americans were nearsighted; three decades later, the rate had risen to 42 percent, and similar increases have occurred around the world.

There is significant evidence that the trait is inherited, so you might wonder why our myopic ancestors weren’t just removed from the gene pool long ago, when they blundered into a hungry lion or off a cliff. But although genes do influence our fates, they are not the only factors at play.

In this case, the rapid increase in nearsightedness appears to be due to a characteristic of modern life: more and more time spent indoors under artificial lights.

Our genes were originally selected to succeed in a very different world from the one we live in today. Humans’ brains and eyes originated long ago, when we spent most of our waking hours in the sun. The process of development takes advantage of such reliable features of the environment, which then may become necessary for normal growth.

Researchers suspect that bright outdoor light helps children’s developing eyes maintain the correct distance between the lens and the retina — which keeps vision in focus. Dim indoor lighting doesn’t seem to provide the same kind of feedback. As a result, when children spend too many hours inside, their eyes fail to grow correctly and the distance between the lens and retina becomes too long, causing far-away objects to look blurry.

One study published in 2008 in the Archives of Ophthalmology compared 6- and 7-year-old children of Chinese ethnicity living in Sydney, Australia, with those living in Singapore. The rate of nearsightedness in Singapore (29 percent) was nearly nine times higher than in Sydney. The rates of nearsightedness among the parents of the two groups of children were similar, but the children in Sydney spent on average nearly 14 hours per week outside, compared with just three hours per week in Singapore.

Similarly, a 2007 study by scholars at Ohio State University found that, among American children with two myopic parents, those who spent at least two hours per day outdoors were four times less likely to be nearsighted than those who spent less than one hour per day outside.

In short, the biological mechanism that kept our vision naturally sharp for thousands of sunny years has, under new environmental conditions, driven visual development off course. This capacity for previously well-adapted genes to be flummoxed by the modern world can account for many apparent imperfections. Brain wiring that effortlessly recognizes faces, animals and other symmetrical objects can be thrown off by letters and numbers, leading to reading difficulties. A restless nature was once helpful to people who needed to find food sources in the wild, but in today’s classrooms, it’s often classified as attention deficit hyperactivity disorder. When brains that are adapted for face-to-face social interactions instead encounter a world of e-mail and Twitter — well, recent headlines show what can happen.

Luckily, there is a simple way to lower the risk of nearsightedness, and today, the summer solstice — the longest day of the year — is the perfect time to begin embracing it: get children to spend more time outside.

Parents concerned about their children’s spending time playing instead of studying may be relieved to know that the common belief that “near work” — reading or computer use — leads to nearsightedness is incorrect. Among children who spend the same amount of time outside, the amount of near work has no correlation with nearsightedness. Hours spent indoors looking at a screen or book simply means less time spent outside, which is what really matters.

This leads us to a recommendation that may satisfy tiger and soccer moms alike: if your child is going to stick his nose in a book this summer, get him to do it outdoors.