Open Letter to Insurance Companies re: BMI-Based Incentives/Penalties

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Background:

Around 2013, the Afford Care Act (ACA), Equal Employment Opportunity Commission (EEOC,) and HIPAA ignored long-standing rules around the Americans with Disabilities Act, and Genetic Information Nondiscrimination Act (GINA) et al. in order to carve out a loophole for weight stigma within employee wellness programs.

They allowed employers to penalize people for their body size, or for failing to manipulate their body size to a lower number or height/weight ratio (AKA BMI.) (Sometimes, rather than being clear that they are penalizing fat people, these are couched as “incentives” for not fat/less fat people, but that’s just semantics.)

Employees can be penalized up to 30% of the applicable health insurance premium.

The excuse used for allowing this was that the programs were “voluntary,” meaning that if you refused to submit to medical testing or BMI calculation (which is not a medical test, but just a height/weight ratio) you were “volunteering” to pay more in premiums than those who were willing to submit to the testing/calculation. It’s important to note that, as with all weight stigma, this does the most harm to those of the highest weights (including because they don’t even have the (horrible) chance to very unhealthfully crash dieting once a year to “make weight” so they aren’t charged more for their insurance,) as well as those with multiple marginalized identities, as those folks tend to be hired, paid and promoted the least, thus making them the least likely to be able to afford additional insurance premiums.

There is a HIPPA requirement that programs have to offer reasonable alternatives for individuals for whom meeting the required standard (for example, BMI) is unreasonably difficult due to a medical condition. I would suggest that the hundred years of data that we have showing that long-term significant weight loss almost never works should be enough to qualify all fat people for exemption, but that’s a topic for a different day.

There are new rules proposed to close some of these loopholes, but they are currently on hold.

So for now, I offer this letter.

Letter:

Content notes: First of all, I reject the entire premise of charging people more for health insurance based on health, size, age, etc. I think that workplace-based health insurance is a particularly terrible idea and this kind of nonsense is part of why. That said, for this particular letter, I’ve only made an argument about BMI-based incentives. I wrote this for a consulting client in a specific situation, who then generously gave me permission to share it here. Feel free to change it up to work for your situation. Please also note that some of the citations below lead to sources that use stigmatizing language for fat bodies and are not fully fat-affirming. Finally, the brackets indicate options for customization.

Dear [Insurance Company/HR Contact],

I am writing today to ask that you rescind your policy of [incentives/penalties] based on BMI because they create financial inequalities based on a metric that fails to accurately measure health, and they disproportionately harm People of Color and those of lower socioeconomic status, while offering little to no health improvement, in some cases decreasing health.

BMI is not a measure of health

BMI is simply a ratio of weight and height, based on teh work of the statistician Quetelet in the1830’s. BMI only measures size, not health. People with the same BMI can have vastly different health statuses, and people of vastly different BMIs can have the same health status.

BMI-based [discounts/incentives] disproportionately impact People of Color and those of lower socioeconomic status

Quetelet’s stated goal was not to create a health measurement, but to create a definition of “ideal” against which “everything differing from his proportion or condition, would constitute deformity or disease ... or monstrosity.”(1)

This is problematic on its face, made more so by the fact that the vast majority of his sample consisted of European cis white men. Thus, the index created based on Quetelet’s work was not created to apply to populations outside of European cis white men. For this reason, the use of BMI increases structural racism. As Sabrina Strings has pointed out, blaming body size for health issues that Black women experience is rooted in the racist 19th-century idea that Black women would eventually die off due to their "animal appetites'' and “unwieldy size.”(2) Da’Shaun Harrison further explains that “From the moment white Europeans saw fat Africans, the science that followed was intended to always separate them from the rest. In this way, the BMI—created to maintain whiteness as superior —was always going to harm the Black fat and it is for this reason that Black people make up over half of the fat population and why Black people also have more ‘health risks' than their white counterparts.”(3)

Those with lower socioeconomic status also tend to have higher BMIs, meaning that these [incentives/penalties] further harm those already struggling financially, creating even greater difficulties in accessing and affording health-supporting options and behaviors.

BMI-based [incentives/penalties] can decrease health

Research shows that the vast majority of people who attempt intentional weight loss lose weight short-term but gain it back long-term, with many gaining back more than they lost. (4) This weight cycling is linked to health issues including increased all-cause mortality, cardiovascular disease, high blood pressure, diabetes, and more. (5) By encouraging employees to try to change their BMI, these policies rarely lead to lowered BMI long-term, but can lead to decreased health.

Many healthcare practitioners are shifting their focus to weight-neutral interventions which are shown to have a greater benefit with fewer risks. (6)  For the clients of those practitioners BMI-based [incentives/penalties] can financially penalize employees for following their healthcare providers’ advice.

Finally, employees who may be at risk for, currently experiencing, or recovering from eating disorders can be forced to engage in a weigh-in that may cause an increase or relapse of these dangerous conditions, or be financially penalized for protecting their physical and mental health by opting out or not wanting to disclose these conditions to their employer. This will, again, disproportionately impact those who are also People of Color and/or of lower socioeconomic status who may have less of an option to pay more for insurance in order to protect themselves.

Considering that BMI-based [incentives/penalties] create financial inequalities that target People of Color and those of lower socioeconomic status and rarely result in lowered BMI, but do risk harming employee health, I respectfully request that you cease the use of BMI in your [incentive/penalty] structure.

References

(1)      Quetelet, L. (2013). A Treatise on Man and the Development of his Faculties (Cambridge Library Collection - Philosophy) (R. Knox, Trans.; T. Smibert, Ed.). Cambridge: Cambridge University Press.

(2)      Strings, S. (2019). Fearing the black body: The racial origins of fat phobia. https://www.sabrinastrings.com/books

(3)      Harrison, Da’Shaun L. “Belly of the Beast” Excerpt: The War on Drugs and The War on Obesity. (2021, April 28). https://dashaunharrison.com/belly-of-the-beast-excerpt-the-war-on-drugs-and-the-war-on-obesity/

(4)      Mann T, Tomiyama AJ, Westling E, Lew AM, Samuels B, Chatman J. Medicare's search for effective obesity treatments: diets are not the answer. Am Psychol. 2007 Apr;62(3):220-33 https://pubmed.ncbi.nlm.nih.gov/17469900/

(5)      O’Hara L, Taylor J. What’s Wrong With the ‘War on Obesity?’ A Narrative Review of the Weight-Centered Health Paradigm and Development of the 3C Framework to Build Critical Competency for a Paradigm Shift. SAGE Open. April 2018. https://journals.sagepub.com/doi/10.1177/2158244018772888

(6)      Hunger, Jeffrey M., Smith, Joslyn P. , Tomiyama, A. Janet An Evidence-Based Rationale for Adopting Weight-Inclusive Health Policy https://jeffreyhunger.com/uploads/3/4/4/8/34481134/hunger_smith___tomiyama__2020__-_sipr.pdf

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More Research

For a full bank of research, check out https://haeshealthsheets.com/resources/

*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings: Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrisons Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.