June 20, 2007

It's About Health

n recent weeks, I attended and spoke at the Mackinac Policy Conference in Michigan, and visited Congressional staff experts on health care, as well as some of our elected representatives. I have seen two points of view expressed by different stakeholders.

At Mackinac and in other forums where companies are faced with overwhelmingly large retiree medical obligations or onerous active employee medical programs that resulted from collective bargaining frameworks agreed upon decades ago, many company and union representatives expressed the view that the government should take over or  redistribute the burden of health care costs away from the employer.

On the other hand, in discussions with others who do not face this legacy burden, there is more recognition that an employer-based health program has a vital role to play in any future health care system.

We have been at a point at which our health care costs were overwhelming, since, up to the late 1980’s, we were paying close to 100% of both our employee and retiree health care costs, and, even today, we have a legacy population of close to 2,000 retirees who still have the pre-1990 100% plan.

But we changed direction in 1990 when I took over responsibility for Human Resources.  We have been a laboratory of sorts in trying new approaches, and I feel we have a great story to tell.  At the same time, I am frustrated because the media, and, too often, elected officials focus too narrowly on the underlying issues.

The purpose of a health care program should be that the people covered by it are as healthy and productive as they can be. Obviously, health care system access, coverage, and cost are critical to making sure that the health care system plays its role in maximizing health and productivity.  But these components are not enough.  While many who propose solutions to the health care crisis will discuss health improvement, it is an after-thought or a component of one of these structural solutions.

Discussing health care without discussing the root causes of deteriorating health is as incomplete as confronting a widespread failure of a mass-market product like brakes on an automobile by focusing on abundant, affordable brake repair shops, and, failing that, making sure that the government steps in to negotiate with all the brake repair shops.  Imagine if those discussing the massive brake failure problem generally failed to ask why the brakes failed in the first place.

We need to ask why Americans are not as healthy as they can be before we confront the issue of how we treat the diseases and injuries that indicate that health deterioration.  In other words, it’s about health, not health care.

What’s making us less healthy?

Let’s start with obesity caused by bad eating habits and inadequate exercise and fitness.  Obesity drives diabetes, cardio-vascular diseases, and orthopedic problems, as well as contributing to injuries.  In fact, the Robert Wood Johnson Foundation and other authorities clearly point out that chronic and complex diseases arising from lifestyle-related conditions like diabetes are the most significant contributors to our spiraling health care costs.

Beyond obesity, lifestyle-related health conditions, such as those brought on by smoking, alcohol and drug abuse, including performance-enhancing drugs drive up our costs.

We tolerate unhealthy communities with environmentally-induced conditions, like the significant increase in asthma in high air-pollution areas.

We are one of the most violent societies in any developed country in which a war is not being fought.

All of these conditions are preventable, and, if we were to improve our health to a level comparable to other developed countries, our health care costs would be far lower, and most of the problems of coverage and access would melt away.

With respect to obesity, I read a great book recently called Mindless Eating: Why We Eat More Than We Think by Brian Wansink.  Wansink has a great quote in the book:  “The best diet is the one we do not know we are on.”  He makes a number of points strongly supported by scientific study and common sense:

  • We gain weight not because of short-term eating binges on unhealthy foods, but because we consistently ingest slightly more daily calories than we burn off.  Likewise, we can lose weight if we burn off slightly more calories than we consume.  For example, if our calorie intake to maintain our existing weight is 3500 calories per day, a 100-calorie swing up or down makes a difference of 10 pounds more or less over a year.
  • The most sustainable weight-reducing diet is one in which we consume between 100 and 300 calories less than we burn off.  Diets based on depriving ourselves of kinds of foods that we enjoy or significant calorie reductions below maintenance level are not sustainable, or unbalanced diets in which we do not eat certain food types like carbohydrates are not healthy or sustainable. I know, because I have lost weight on many different diets in which I have deprived myself of foods I liked, but ultimately could not sustain them.
  • Many techniques can reduce the marginal intake of the food that makes a difference between weight gain and loss, and many are as simple as not putting ourselves in situations in which eating is the easiest thing to do.  Some techniques are as simple as buying, or keeping, or measuring smaller quantities of food.
  • Some highly-appearing foods are highly likely to result in overeating if easy to access, such as desserts and other sugary foods, simple carbohydrate foods like pizzas and pasta, and snacks.  The best approach to those foods is to reduce ease of access.

We tried many of these techniques at our Company facilities and they work.  For example, the healthy food is easy to find and the foods that we tend to overeat, like cookies, cupcakes, and potato chips, are harder to find.  We are very careful with portion control.  We follow traditional retail merchandising techniques by putting foods we want people to eat, like fresh fruits, right near the check-out counter.

Outside the cafeteria, we make bottled water readily available everywhere, but make sodas and snacks from vending machines hard to find.  We eliminated food service at breakfast meetings, and significantly reduced the quantities of the food we provided at luncheon meetings.

Alcohol is served for a limited period of time at after-work parties, and is served in relatively small glasses or cups.  Cocktail periods at parties are relatively short, and we try to get as many functions held at our Company dining facilities and as few at outside facilities as possible, especially restaurants that make their profits on alcohol and desserts.

With respect to fitness, we give away pedometers and encourage people to participate in 10,000 steps-per-day programs, and we subsidize fitness facilities, including fitness centers in our Headquarters and our Technology Center.

We prohibit smoking at Company facilities, and we actively promote smoking cessation programs.

People like our health programs, and we have many inspiring and emotionally-satisfying stories of employees whose lives have been turned around by our programs.

I do not believe in coercing good behaviors.  I am appalled by companies that threaten to fire smokers or refuse to hire them in the first place.  I am also appalled by what I have heard about companies that humiliate obese people by communicating their Body Mass Index to them, and by requiring them to go into fitness programs as a condition to a better job.  They are unhappy enough being obese.  Why pile on?  I believe in the carrot, rather than the stick.

I also find it ironic that I go to many health-related conferences and the same junky food we talk about stopping our children from having at school is served at coffee breaks and lunches at the conferences.

What I have tried to do is to create a culture of health. Helping people with diet, fitness and exercise, and lifestyle issues like smoking and drug abuse are obvious.  Alcohol consumption is more challenging, because it is less clear whether the right answer is no alcohol consumption or modest alcohol consumption, particularly of red wine.

My approach to alcohol has been to try to establish a culture in which individuals can make the appropriate health decision whether to refrain or to consume modestly.  Many companies, including ours, had a culture from previous generations in which heavy alcohol consumption was associated with fun and being sociable.  What I’ve tried to do is to make the decision whether to refrain or to consume moderately a personal choice, and to make sure that people at our Company know that heavy alcohol consumption, especially when coupled with driving, is a serious problem.

We try to create a culture of health at home as well with our children in terms of what they eat and drink.  The foods we serve and buy, the peer groups with which they connect, and the welcoming environment we create are more successful than the silly rules I see at the schools these days.  Letting children have a celebration with sweets once in a while is not going to change the culture of health, especially if schools monitor the portions served.  At the same time, schools need to focus on physical fitness, smaller food portions, and a better mix of healthy, tasty foods than they have today.

We take long walks with our children and have nice conversations.  One of my favorite movies from the 1980’s wasThe Karate Kid because the hero was training without realizing it, as he was doing chores.  Fitness needs to be fun and to be accomplished as part of something else.

One of my colleagues on an outside board of directors told me about an analysis someone had done about adult lives 50 years ago and why adults were not as obese then.  They expended from 50-100 calories per day more energy on day-to-day living tasks because automated solutions were simply not available then.

Think about the days before TV remote controls, automatic garage door openers, automatic car windows, electric or gas-powered lawn mowers or snow removers.  Those extra 50-100 calories per day gave adults a 5-10 pound per year head start over us in terms of weight management.  I replicate that with the 10,000 steps program, and stay in motion as much as possible.

I would love to see politicians focus on creating a national culture of health, as opposed to trying to rearrange the deck chairs on the Titanic by coming up with a different way to distribute the pain of current health care costs.

I am pleased with some of what I see in Congress with the thinking of many U.S. Senators on both sides of the aisle.  Senators Wyden, Whitehouse, Coburn, and Smith are among those trying to find solutions that focus on health, as well as health care. I am also pleased that Senator Clinton spoke favorably about our health care program.

The good news is that there is a lot of momentum to reform health care.  In our rush to enact a much needed health reform bill I hope we do not inadvertently knock out programs like ours that actually are working to reduce costs and achieve health improvement at the same time.  Let’s deal with the legacy issues that plague some of our older companies and, by the way, our government employee health plans, but let’s not let those legacy issues drive the broad health care reform agenda.