# N.C. to impose 'fat tax'

## Smokers to pay more, too

Staff WriterOctober 7, 2009

• July 2010: Nonsmokers and smokers in cessation programs will be able to move into a cheaper health insurance plan in which they pay 20 percent of medical costs, while tobacco users will remain in a plan in which they pay 30 percent of medical costs. Random tests will check for tobacco use.

July 2011: Health plan members whose body mass index is greater than 40 will have to remain in the more expensive insurance plan. A 6-foot-tall adult must weigh 295 pounds to reach a BMI of 40.

• Take your height ininches and square it.

Divide your weight in pounds by the height figure.

Multiply that by 703.

Example: Weight = 150 pounds, height = 5 feet, 5 inches (65 inches)

[150 ÷ (65) {+2}] x 703 = 24.96

What it means

18.5 or less - underweight

18.5 to 24.9 -- normal

25 to 29.9 -- overweight

30 or above -- obese

Source: CDC

— North Carolina is poised to become only the second state to impose a fat fee on its state employees by placing them in a more expensive health insurance plan if they're obese.

Smokers will feel the drag of higher costs, too, as North Carolina state employees who use tobacco are slated to pay more for health insurance next year.

North Carolina officials, coping with a steady uptick in health-care costs for state employees each year, are aiming to improve state workers' health, which saves money in medical expenses.

"Tobacco use and poor nutrition and inactivity are the leading causes of preventable deaths in our state," said Anne Rogers, director of integrated health management with the N.C. State Employees Health Plan. "We need a healthy workforce in this state. We're trying to encourage individuals to adopt healthy lifestyles."

State workers who don't cut out the Marlboros and Big Macs will end up paying more for health care. Tobacco users get placed in a more expensive insurance plan starting in July and, for those who qualify as obese, in July 2011.

Some state employees, though, are criticizing the planned changes. The State Employees Association of North Carolina opposes the tobacco and obesity differentials as invasive steps that could have been avoided if the legislature had fixed the plan.

'An invasion of privacy'

"It's my understanding they're talking about testing [for tobacco use] in the workplace which, to me, would create a hostile environment," said Kim Martin, a sergeant at Piedmont Correctional Institution in Salisbury. "And it's an invasion of privacy. This is America, the land of the free. I don't think [body mass index is] a very good measure. I know some folks who would have a high body mass index because they're muscular."

The health plan covers more than 600,000 state employees, retirees and teachers at a total cost last year of \$2.6 billion. Last spring, the legislature bailed out the plan with an infusion of \$250million to pay the bills after rising costs and inaccurate projections left little money for claims. Over the next two years, the state general fund will pump about \$408 million into the health plan.

Although officials have not yet estimated any potential savings from the obesity requirement, the higher costs for smokers could save \$13million in the 2010-2011 budget year, Rogers said, emphasizing that the plan's priority is to improve health and save money in the process.

The idea of penalizing unhealthy lifestyles and rewarding healthy conduct is hardly new among insurance plans. Public health insurance plans in other states already penalize smokers or reward nonsmokers in insurance costs. South Carolina's state employees health plan is scheduled to add a \$25-per-month surcharge on smokers in January. Elsewhere in the Southeast, Kentucky and Georgia impose surcharges, and Alabama gives nonsmokers a discount.

Weight checks

Alabama was out front on weight testing. Starting in January, state workers will have their blood pressure, cholesterol, glucose andbody mass index checked by a nurse. If they're in a risk category, such as a body mass index of 35 or greater or a blood pressure of 160/100 or greater, they are charged an extra \$25 per month on their insurance premium. If they go to a health screening, either offered by the state or by their personal physician, then the \$25 is subtracted, according to Gary Matthews, chief operating officer for the Alabama State Employees Insurance Board.

North Carolina will allow state workers with a BMI of up to 40 to keep the discount, although some experts consider anyone with a BMI of 30 to be obese.

Private sector employers appear to have been targeting tobacco and weight in their insurance pricing ahead of state health plans.

Two risk factors

"We're beginning to see a lot of employers extremely interested in this," said Tim Smith, president of BioSignia, in Durham, which provides for private employers a system of measuring employees' risk factors for the onset of chronic disease. The company presents only aggregate data to the employers and does not disclose information about individuals, Smith said.

Tobacco and obesity are leading risk factors for ailments such as heart disease, stroke, type 2 diabetes and chronic breathing disorders. BioSignia is not under contract with the state health plan, but Smith said that employers like the state are trying to catch employees who are in pre-disease stages to save both lives and money.

Only a fraction of employers, though, offer financial incentives for healthy behavior or wellness programs, such as gym memberships or smoking cessation, according to a Kaiser Family Foundation study last year. Differences in employees' education, health literacy and access to basic health care could affect the usefulness of financial incentives in reducing health-care costs over time, the study said.

The results are not yet in. The higher costs for smokers and the obese don't appear to have been in place long enough for any state to boast of a healthier workforce yet, according to officials in several states.

Where is the data?

"I don't know that any states have a lot of hard data on this," Rogers said.

The policies have generated a backlash among at least a portion of state workers. Some workers are anxious about the idea of tests for smoking.The tests involve examining a saliva sample for cotinine, a derivative of nicotine found in the system of tobacco users. Health plan officials recognize those concerns and are getting ready to take bids from companies that will perform the tests. The state plan has not yet developed a procedure to monitor members for the obesity standard due to take effect in 2011.

"We're going to have to work out those logistics," Rogers said.

Martin, the prison sergeant in Salisbury, doesn't smoke but considers herself overweight. Instead of financial penalties, she would like to see financial subsidies.

"If they're going to hold us accountable," Martin said, "pay for a gym membership or part of a membership. Give us an incentive, a way to combat it."

mjohnson@charlotteobserver.com or 919-829-4774

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