Health at Work

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REV: MAY 26, 2016
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JOHN A. QUELCH
EMILY C. BOUDREAU
Employee Health
On June 15th, 2015, CNNMoney published a short article titled “Amazon is America's best company.
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Says who? You!” According to the Reputation Institute, a firm that assesses public opinion on
companies and industries, Amazon had the highest rating of any company in the U.S. The Reputation
Institution stated that they determined ratings by measuring “a company's ability to deliver
expectations in its products and services, innovation, workplace, governance, citizenship, leadership
and financial performance.”1 By this account, it seemed that Amazon was not only meeting the
demands of consumers, but surpassing other companies in their efforts.
Two months later, the New York Times featured an article on Amazon’s workplace culture, depicting
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it as competitive, aggressive, and unforgiving for their employees. The article stated:
Many of the newcomers filing in on Mondays may not be there in a few years. The
company’s winners dream up innovations that they roll out to a quarter-billion customers
and accrue small fortunes in soaring stock. Losers leave or are fired in annual cullings of
the staff — “purposeful Darwinism,” one former Amazon human resources director said.
Some workers who suffered from cancer, miscarriages and other personal crises said they
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had been evaluated unfairly or edged out rather than given time to recover.2
The article described how coworkers would often see one another cry and some employees
struggled to remain at the employer due to high stress levels. The New York Times published a second
article showcasing a handful of the comments and responses they received, some from Amazon
employees themselves.3 Some commenters reinforced the view the idea that Amazon had created an
overwhelmingly stressful workplace, while others rushed to defend the technology company, stating
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that the benefits of working with thoughtful, driven coworkers on cutting-edge technology issues far
outweighed the drawbacks of a fast-paced environment.4
In 2014, Harvard Business Review’s CEO ranking was based entirely on financial performance
measures, and Jeff Bezos, Amazon’s founder and CEO, ranked first. In 2015, Mr. Bezos ranked 87th.5
The ranking system had changed in 2015, with 80% of a CEO’s score based on the traditional financial
performance measures and 20% based on a company’s environmental, social, and governance (ESG)
impact. Harvard Business Review stated, “On the purely financial metrics, Amazon’s Jeff Bezos leads all
other CEOs—just as he did last year. But Amazon’s relatively poor ESG score drags Bezos down to #87
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overall.”6
Professor John A. Quelch and Research Associate Emily C. Boudreau prepared this case. This case was developed from published sources. Funding
for the development of this case was provided by Harvard Business School and not by the company. Professor Quelch is the Charles Edward
Wilson Professor of Business Administration at Harvard Business School and Professor in Health Policy and Management at the Harvard T.H.
Chan School of Public Health. HBS cases are developed solely as the basis for class discussion. Cases are not intended to serve as endorsements,
sources of primary data, or illustrations of effective or ineffective management.
Copyright © 2016 President and Fellows of Harvard College. To order copies or request permission to reproduce materials, call 1-800-545-7685,
write Harvard Business School Publishing, Boston, MA 02163, or go to www.hbsp.harvard.edu. This publication may not be digitized, photocopied,
or otherwise reproduced, posted, or transmitted, without the permission of Harvard Business School.
This document is authorized for educator review use only by ALEJANDRA APIQUIAN, Universidad Anahuac until May 2020. Copying or posting is an infringement of copyright.
[email protected] or 617.783.7860
516-074 Employee Health
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While the exact nature of the Amazon workplace remained in dispute, the situation highlighted
several key challenges that many other employers and their employees faced more generally. If
Amazon, an innovative company that provided its employees with competitive salaries, benefits, and
interesting opportunities within the technology industry could face these questions, certainly no
company was immune to employee health and wellness challenges. Indeed, employee health was more
frequently considered a matter of wellbeing, not simply the absence of disease.7
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Could companies create fast-paced environments that drove revenue growth and innovative
consumer offerings while simultaneously promoting physical and mental wellbeing among their
employees? Was employee health an employer responsibility? Did corporate investments in employee
health generate economic and/or social returns? How could corporations create high impact wellness
programs? Were the returns on investments in employee health seen in the short or long-term?
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Context
In 2014, full-time employed American adults spent an average of 47 hours per week working and
18% of adult workers reported working more than 60 hours per week.8 As a result, the nature of an
employee’s work, the health benefits available through their employer, and the level of stress their
work created in both their professional and personal lives had significant impacts on their health.
While investment in employee health was not a new concept, there had been a rise in innovative
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wellness programs and increased debate around the appropriate role of employers in keeping
employees well. Though the incentives for investing in employee health were significant, there were
also many reasons why employers hesitated to make investments in employee wellness. Many
programs aimed at improving employee wellness were resource intensive and required significant
implementation time. This note will assess the drivers behind employer investments in health and
wellness – as well as the benefits and tradeoffs of these investments.
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Why Employers Invest in Employee Health

In 2012, approximately half of the US adult population had at least one chronic health condition
(e.g., cancer, diabetes, obesity, and heart disease). Even more alarming, it appeared that chronic
diseases were increasing worldwide, largely due to poor diet and inactivity.9 (See Exhibit 1 for the
increase in the percentage of US adults who had two or more chronic conditions between two time
periods (1999-2000 vs. 2009-2010)).
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There was growing concern that the increasing prevalence of these conditions threatened the
economic competitiveness of the U.S. In 2014, The Vitality Institute Commission on Health Promotion
and the Prevention of Chronic Disease in Working-Age Americans issued five recommendations for
combatting the increasing prevalence of chronic conditions: invest in prevention science; strengthen
and expand leadership to deliver a unified message for health and prevention; make markets work for
health promotion and prevention; integrate health metrics into corporate reporting; promote strong
cross-sector collaborations to generate a systemic increase in health promotion and prevention across
society.10
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Physical health was not the only challenge – mental health issues, such as depression, were also a
concern. At some point in their lives, 25% of Americans would have a mental health issue, and 1 in 17
suffered from a more serious illness like bipolar disorder.11 12
Employee Health 516-074
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By 2016, six key drivers had strengthened the importance of employer investments in combatting
these significant health challenges many of their employees faced. The drivers were as follows:
1. Adhering to legislation
2. Managing costs
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3. Generating revenue
4. Promoting brand reputation
5. Complying with union agreements
6. Addressing a moral imperative
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Adhering to legislation Though regulations varied substantially across the world, in the U.S.,
most employers were legally bound to adhere to certain standards of workplace safety, and several
government agencies evaluated working conditions. Certain employee benefits, such as Social Security
and unemployment insurance, were mandated. Furthermore, when it was passed in 2010, the Patient
Protection and Affordable Care Act (ACA) placed a new nationwide focus on healthcare in the U.S.
Many of its provisions were directly aimed at providing health insurance to previously uninsured
individuals, reducing the cost of care, and improving the quality of care. While these affected the types
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of health plans employers could offer their employees, the ACA had fewer direct impacts on employers
than it did on previously uninsured individuals, health insurance providers, and healthcare providers.
In 2014, one study analyzed six separate microsimulation models that different researchers and
organizations had created to assess the overall impact of the ACA. Across all of the models, the
estimated change in covered lives ranged from a reduction of 6 million lives to an increase of 8 million
lives.13 The study author concluded that “though there are notable differences, all published
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microsimulation models suggest the overall effects of the Affordable Care Act on [employer-sponsored
insurance] coverage will be modest.”14
Despite the overall modest impact, several provisions did affect employers directly. One such
provision was the Employer Shared Responsibility Provision, which penalized employers with 50 or
more full time workers who did not offer health coverage to their full-time employees.15 (See Exhibit
2 for a detailed overview of the Employer Shared Responsibility Provision.) The ACA also included
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additional incentives for “health-contingent” wellness programs.16 Health-contingent wellness

programs provided rewards based on health outcomes, often meaning that employees who met certain
health criteria received a premium discount or other incentive. The ACA set the maximum reward at
30% of the total cost of health coverage for most programs (shared between the employer and
employee) and stipulated a higher reward amount, 50% of coverage, for tobacco-related programs.17
Managing costs Employers had invested heavily in employee health to mitigate productivity
costs associated with ill employees. These costs included lost productivity due to employee
absenteeism, or “the time an employee spends away from work. Absences [could be] scheduled (e.g.,
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vacation time) or unscheduled (e.g., due to illness or injury).”18 Possibly as equally significant were the
productivity costs associated with presenteeism, the extent to which health issues negatively affected
employees who remained present in the workplace (e.g., an employee contracted the flu, but decided
to attend work and was less productive than he/she was normally).19 If an employee was absent or not
working to his or her full capacity due to an illness, the employer had to use other resources to cover
that loss.20 U.S. corporations lost around $225 billion annually due to absenteeism and presenteeism.21
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Both mental and physical conditions contributed to these losses. For example, a study on the
employer burden of major depressive disorder (MDD) in employees showed that MDD severity was
not only associated with increased treatment usage/costs, but that there was also “a significant
association between MDD severity and adjusted average monthly hours worked, work performance
self-rating, the probability to miss one or more work days in past month, and monthly reduced work
and performance.”22
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Compared with employers in countries like the U.K., where the National Health Service (NHS) was
paid for with tax dollars and supplied by the government, many employers in the U.S. provided
employer-sponsored health insurance as a benefit to aid employees in paying for their care. For these
employers, cost management strategies were also aimed at reducing enrolled employees’ health care
utilization costs. Typically, insurers evaluated health care utilization costs across an employer’s entire
employee population on a routine basis, offering new premiums that appropriately captured the risk
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of that employee population.23 This meant that “all employees within the workplace (or at least within
broad job categories) typically [paid] the same amount for a health plan of given benefits and payment
provisions,” known as a “community rate.”24 Thus, when employees, on average, accessed pricier care,
employers tended to see an increase in health premiums. Keeping employees well had the potential to
reduce health care utilization and premium increases over time.
Health insurance premium increases had skyrocketed throughout the 2000's, and employers were
actively seeking ways to stem the trajectory.25 One report showed that in the time period from 2010 to
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2015, average premiums for covered workers with family coverage increased by about 27%, surpassing
both overall inflation and workers’ earnings, at 9% and 10% respectively.26 (See Exhibit 3 for health
insurance premium increases compared to inflation and workers’ earnings in three distinct time
periods.)
Generating revenue Many employers started seeing the promotion of employee health as more
than a cost management strategy. In the 2014 book The Good Jobs Strategy, Zeynep Ton argued that
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model retailers view their employees as assets and invest in them – and these retailers ultimately
perform better financially.27 Investing in employee health had the potential to improve company
culture, ultimately increasing employee satisfaction and engagement – potentially increasing employee
tenure.28 Healthier, more engaged employees could think more creatively and drive innovative
business ideas and revenue growth.
However, assessing the impact that a healthy, engaged employee could have on revenue growth
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potential proved more difficult than assessing the costs of an ill one. One article accurately portrayed
this challenge by stating:
Even the way the literature addresses health-related lost productivity is cost-based:
the opportunity costs of lost work time, whether from absence or loss of performance. But
research to date tells us little about top-line business performance impacts—how healthier
employees may influence business results and how other health related factors the
employer has influence over can contribute to business outcomes.29
Promoting brand reputation Employers also invested in employee health to improve their
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company and brand reputation. Well-known company ranking systems, such as FORTUNE's 100 Best
Companies to Work For®, depended heavily on employee satisfaction and opinion. Two-thirds of
Fortune's ranking was based on “questions related to employees’ attitudes about management’s
credibility, overall job satisfaction, and camaraderie,” while the final third was based on “questions
about pay and benefit programs and a series of open-ended questions about hiring practices, methods
of internal communication, training, recognition programs, and diversity efforts.”30
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In The Good Jobs Strategy, Ton pointed out that online communities like Glassdoor made it simpler
for employees to anonymously share their experiences with others – discussing how, in August, 2012,
Trader Joe’s scored an 84% on the question, “Would you recommend this employer to a friend?,” while
Walmart scored a 47%.31 Therefore, investing in these areas had the potential to improve a company's
ranking and visibility with potential employees and consumers.
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Promoting employee health and wellness was also often part of a larger corporate social
responsibility (CSR) strategy, which had gained traction and popularity among employers in the 1990’s
and 2000’s.32 Though the authors of one study on consumer decision-making cautioned that the more
traditional drivers of consumer decision-making, price and quality, remained most impactful, they
found a relationship between investments in CSR programs and improved consumer opinion, stating:
Companies that evidence societal responsibility have been rewarded for their efforts
and behaviors – positive word of mouth among consumers, stronger market position, and
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thus superior financial performance, as compared to companies with less responsible
practices.33
Complying with union agreements Labor unions collectively negotiated with employers on
the behalf of employees around issues like working conditions, wages, and benefits. The Wagner Act
of 1935 gave employees the right to form and join unions, and also required employers to work with
them.34 In 1983, the union membership rate among wage and salary workers was 20.1%; however, the
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rate was down to 11.1% by 2014.35 Unions had a more significant role in the public sector, where 35.7%
of workers belonged to a union in 2014, than in the private sector, where only 6.6% of the workers
belonged to a union.36 For industries that were heavily unionized, including teachers and police
officers, union requests represented a final driver for employer investments in employee health.
Addressing a moral imperative While there were clearly business reasons to make
investments in employee health, many corporate leaders and their boards invested in employee health
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because they believed that, morally, it was the right thing to do. The fact was that work was a major
cause of physical and mental stress - and sometimes illness - for many employees. Therefore, many
morally-led companies felt a sense of duty to address employee health concerns – especially those that
were clearly associated with the workplace, such as high stress levels.
How Employers Promote Employee Health

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In October 2015, Danny Meyer, the chief executive of Union Square Hospitality Group (“USHG”),
announced that about a dozen of his New York City restaurants would eliminate the practice of tipping
and increase meal prices to compensate for the difference. This change was in an effort to raise the
wages of dining room managers and kitchen staff, as they did not receive gratuities or share in pooled
tips from wait staff. 37 Mr. Meyer said that over the last 30 years “the gap between what the kitchen
and dining room workers make has grown by leaps and bounds…kitchen income has gone up no more
than 25 percent. Meanwhile, dining room pay has gone up 200 percent.” 38
There was increasing evidence that promoting a positive workplace environment was critical for
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employee health and wellness. Combatting inequity, as the USHG did, was one strategy businesses
took. Others included improving workplace safety standards, changing benefits, raising wage levels,
or improving company culture. Many of these changes were particularly important for combatting
mental health challenges in the workplace.
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The main ways that employers promoted employee health were through changes in the following
areas:
1. Workplace safety
2. Employee benefit programs
• Health insurance
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• Workplace wellness programs
• Mental health programs
• Other company-specific benefits
3. Wage standards
4. Company structure & culture
Workplace Safety
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Workplace safety was one of the most fundamental aspects of employer investments in employee
health and it could contribute to both physical and mental wellness issues if not properly addressed.
In 1884, Germany became the first country to provide compensation to employees who were injured
in workplace-related accidents, and many other countries followed suit not long after.39 Workers’
Compensation laid the groundwork for some of the first, significant employer investments in working
conditions, as it gave employers a financial incentive to avoid work-related accidents. The Department
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of Labor explained the economic incentives of workers’ compensation as:
The economic incentive to employers was tied to the premiums they would pay to the
state or to the insurance company that underwrote compensation payments. Premiums
would vary from industry to industry and from plant to plant, depending on the safety
record, extent of hazards, and the efforts companies made in accident prevention. The
employer would pay a lower rate as safety efforts and the accident record improved in
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his company or his industry. Supporters of workmen's compensation asserted that the
potential savings in premiums would more than cover the costs of necessary safety
improvements, making it in the employers' own best economic interest to reduce accident
rates.40
Occupational safety standards in the U.S. were further advanced in 1970 when President Richard
Nixon signed the Williams-Steiger Occupational Safety and Health Act into law. The Act established
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the Occupational Safety and Health Administration (OSHA), the National Institute of Occupational
Safety and Health (NIOSH), and the independent Occupational Safety and Health Review
Commission.41
While the organizations worked together, NIOSH sat within the U.S. Centers for Disease Control
and Prevention and became largely a research organization, while OSHA was a part of the U.S.
Department of Labor and took on a regulatory and enforcement role.42 The Occupational Safety and
Health Review Commission was an independent federal agency that reviewed employer appeals to
OSHA decisions.43
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Although significant advancements occurred across most industries, some occupations remained
riskier than others. In 2014, the industries with the greatest number of fatal occupational injuries were
construction, transportation and warehousing, and agriculture, forestry, fishing, and hunting. See
Exhibit 4 for workplace fatalities by sector in 2014.
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Despite the progression of workplace safety standards in the U.S., the April 2013 collapse of the
Rana Plaza building in Bangladesh highlighted that workplace safety was still an important challenge
to employee wellness globally. The building collapse resulted in the death of over 1,100 factory
employees and rescue workers.44 The event caused international outcry, and in June 2015, Bangladesh
charged 41 people involved with murder charges.45
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Primark Stores Ltd. (“Primark”), a division of Associated British Foods (ABF) and an Irish clothing
manufacturer, had a contract with one of the garment factories in the Rana Plaza building. It responded
quickly to compensate the victims of the Rana Plaza tragedy. To fairly and appropriately distribute aid,
Primark developed a three-part strategy that included an actuarial model, a medical assessment and a
vulnerability assessment.46 In March of 2015, Primark publically announced that the company had
distributed more than 95% of the expected long-term compensation payments. At that time, Primark
had contributed a total of $14 million to victims.47 Primark's reaction to the tragedy highlighted the
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ongoing importance of employer investments in creating and promoting a safe working environment.
The company’s actions also showcased how taking socially conscious actions when that fails can restore
employee faith and improve public relations.
Employee Benefit Programs

Employee benefit packages had become a staple component of total compensation. In 2015, the U.S.
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Bureau of Labor Statistics reported that private industry employers spent an average of $31.39 per
employee for each hour worked, with wages and salaries accounting for 69.5% of that total and benefits
accounting for the remaining 30.5%.48
Beyond legally mandated benefits, employers used employee benefit programs to attract and retain
employees. For example, most Silicon Valley startup companies provided subsidized or free healthy
food options for lunch.49 Many millennials considering employment at such companies all but
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demanded this perk. One Business Insider article stated, “Free snacks, yoga class, bottomless drinks,
and a back massage may sound like a night at an all-inclusive luxury resort, but for employees at
Pinterest it’s just another day at the office. Tech companies desperate for talent are engaged in an all
out free perks arms race…”50
While there were some employee benefits that were more directly linked to employee health (e.g.,
health insurance and wellness programs that promoted physical and mental health), there were many
more that were tied indirectly. These included retirement, paid leave (maternity, paternity, illness),
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financial incentives (e.g, stock options, bonuses), and flexible work arrangements.
Google Inc.’s (“Google”) investment in mental wellbeing showcased the way that many companies
were placing a newfound focus on innovative benefits that improved employee wellness in less
traditional ways. The company provided several avenues for employees to assess and address their
stress. Google's Search Inside Yourself program focused on mindfulness to develop resilience,
acknowledging that their employees’ work could be stressful, but that there were healthful ways to
address that stress.51
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Chade-Meng Tan was Google’s “Jolly Good Fellow,” and his job was to foster emotional wellbeing
and happiness among Google employees. Although he started as an early engineer at Google, Mr. Tan
later created and taught a class at Google on mindfulness.52 2,000 employees had taken his class, and
Mr. Tan believed that mindfulness led to increased kindness, and ultimately, better business
practices.53 He said:
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In many situations, goodness is good for business...If you, as the boss, are nice to your
employees, they are happy, they treat their customers well, the customers are happy to
spend more money, so everybody wins. Also if you treat everybody with kindness, they'll
like you even if they don't really know why. And if they like you, they want to help you
succeed. So it's good for your soul and it's good for your career.54
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Health Insurance
One of the employee benefits most directly linked to health was employer-sponsored health
insurance. In 2015, over half of the non-elderly population in the United States was covered by
employer-sponsored health insurance. 55
As previously noted, health insurance premiums had increased significantly across the 2000's. 56 In
employer-sponsored plans, premiums were partially funded by the employer and partially funded by
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the employee. The employee share of the premium had remained relatively stable for the prior two
decades, meaning that premium costs were increasing for both the employer and employee.57
However, Katherine Baicker and Amitabh Chandra noted that “increases in health insurance
premiums do not get absorbed by an unlimited reservoir of profits or endowments—they are paid for
by employees taking home smaller paychecks.”58 This suggested that premium increases were
ultimately financed by the employee.
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To control the increases in premiums and encourage employees to take more active roles in their
own care, employers and health insurance providers had used cost-shifting mechanisms. This trend
was most abundantly clear through the proliferation of high-deductible health plans (HDHPs).59 (See
Exhibit 5 for trends in HDHPs.) HDHPs had lower monthly premiums than more traditional plans.60
Employees typically still received catastrophic coverage in the event of a serious illness and lower,
negotiated prices due to their participation in the plan. However, because the plans offered lowered
premiums, they came with higher deductibles that employees had to meet through out-of-pocket
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spending. 61
Did this switch empower employees to price shop and become savvier consumers of care, or did it
cause them to avoid care in an effort to reduce out-of-pocket costs? In a 2015 study published by the
National Bureau of Economic Research (NBER), researchers found that when employees were required
to switch from an insurance plan that provided free health care to an HDHP, total healthcare spending
went down – due entirely due to reductions in the quantity of care.62 These reductions were seen for
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both “potentially valuable care (e.g. preventive services) and potentially wasteful care (e.g. imaging
services).” 63 Interestingly, the researchers found no evidence that employees were price shopping for
care within two years of switching to the HDHP coverage. 64
Cost-sharing mechanisms, such as increased deductibles and copayments, seem to have had both
benefits and drawbacks.65 They might have reduced the overuse of medical care and reduce further
premium increases, but they also had the potential to dissuade an individual from accessing necessary
care.66 In 2015, Baicker and Chandra suggested that a more nuanced understanding and use of cost-
sharing mechanisms (e.g., how cost-sharing mechanisms affect different kinds of care and patients with
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different income) was necessary to “improve health, slow increases in health insurance premiums, and
increase take-home pay.”67
The ACA required employers with more than 50 full-time employees to provide health insurance
to employees working more than 30 hours a week.68 Part-time workers who did not obtain coverage
through their employment were able to purchase health insurance on the Health Insurance
Marketplace. In 2014, Walmart raised premiums for all employees and cut health insurance benefits
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for 30,000 part-time employees who worked less than 30 hours a week.69 This group made up about 2-
5% of the company’s part-time workforce at the time.70 71 Walmart defended their decision with a blog
post on their website. It stated:
Like every company, Walmart continues to face rising health care costs. This year, the
expenses were significant and led us to make some tough decisions as we begin our
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annual enrollment. As a result, today we announced that our associates will see an
increase in premiums for 2015. For example, our most popular and lowest cost associate-
only plan will increase by $3.50 to $21.90 per pay period – still half the average premium
other retail employees pay.
We’re also changing eligibility for some part-time associates. We will continue to
provide affordable health care to all eligible associates, including part-time, who work
more than 30 hours. However, similar to other retailers like Target, Home Depot,
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Walgreens and Trader Joe’s, we will no longer be providing health benefits to part-time
associates who work less than 30 hours.72
Workplace Wellness Programs

In 2015, more than 80% of U.S. employers offered an employee wellness program as a benefit to
help employees lose weight, improve chronic health conditions, stop smoking or make other healthy
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lifestyle modifications.73 Though definitions of workplace wellness programs have varied, in 2012, a
comprehensive review of workplace wellness programs defined a workplace wellness program with
the following statement:
Broadly, a workplace wellness program is an employment-based activity or employer

sponsored benefit aimed at promoting health-related behaviors (primary prevention or
health promotion) and disease management (secondary prevention). It may include a
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combination of data collection on employee health risks and population-based strategies

paired with individually focused interventions to reduce those risks. A formal and
universally accepted definition of a workplace wellness program has yet to emerge, and
employers define and manage their programs differently.74
Some employers created their own programs, but many used third-party wellness vendors. By 2014,
workplace wellness was a $6 billion dollar industry in the U.S.75 The industry had grown rapidly, and
some of the programs had become highly personalized. For example, Newtopia, a genetics-based
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wellness program offered genetic testing followed by personalized coaching for disease prevention.76
Programs varied in their goals, scope, cost, and use of incentives. Incentives were used to encourage
eligible employees to take part in available workplace wellness programs. In 2014, one study found
that the employee participation rate for employers that did not use incentives was around 20%, while
employers who used rewards had a 40% participation rate, and employers who used penalties and/or
rewards had a 73% participation rate.77
In 2015, The Institute for Health and Productivity Studies at the Johns Hopkins Bloomberg School
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of Public Health collaborated with the Transamerica Center for Health Studies to explore, among other
things, which incentives were most likely to change employees' behaviors in a cost effective way.
Although many programs provided some type of incentive, its findings indicated that it was important
to provide positive, visible rewards related to healthcare; what’s more, some companies opted to give
rewards smaller rewards over time to sustain employee engagement.78
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Questions remained about the future wellness program incentives, as there had been several
lawsuits over their use and there were several more pending in early 2016.79 In one case, a corporation
denied health insurance coverage to a worker who refused to participate in the employer's work-
sponsored health assessment and biometric screening.80 In 2015, a federal court judge in Wisconsin
ruled in favor of that employer – reasoning that employers could require health assessment
participation and deny coverage so long as the data obtained was used for determining the overall risk
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of its insurance pool.81
Some companies that had heavily invested in employee health had seen significant returns. Johnson
& Johnson (J&J), a medical device, pharmaceutical, and consumer packaged goods company, had made
employee health and wellness a priority for decades. The company also evaluated many of its wellness
investments, which cost over $60 million per year by 2014,82 over time. In 2014, J&J’s “Culture of
Health” 12-program framework included a tobacco-free workplace, free health profiles, an employee
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assistance program, medical surveillance, physical activity, health promotion, stress and energy
management, cancer awareness, HIV/AIDs awareness, healthy eating, modified duty/return to work,
and travel health. All global locations participated, though program content was customized by
location and culture. Health tools included prevention-focused education, rewards for healthy
behaviors, and workplace environments that made it natural for employees to engage in healthy
behaviors.83
J&J began to collect data on health-related savings from their investments in wellness programs as
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early as the 1990s. In 1995, medical claims for around 19,000 U.S.-based employees who participated in
the Health&Wellness program showed an average total savings of $224.66 per employee across all
expenditure categories, with savings becoming more significant over time.84 A separate study analyzed
employee health risk and cost data from 2002-2008. Researchers found that the average J&J employee
had a lower predicted probability of being at high risk for high blood pressure, high cholesterol, poor
nutrition, obesity, physical inactivity, and tobacco use; however, J&J employees were at higher risk for
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depression and stress than employees in an external comparison group.85 In the time period studied,
2002-2008, J&J’s medical spending grew at a 3.7% lower annual rate than at comparable U.S.
companies.86 87
Despite successes like J&J and the widespread and increasing use of workplace wellness programs,
many expressed concerns with the programs, which included:
1. Unknown or lack of impact

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2. Inadequate protection of employee privacy
3. Creation of a toxic or competitive workplace culture
In 2012, one study assessed 33-peer reviewed publications on workplace wellness programs and
found that only five provided ROI estimates. The ROI estimates were modest and ranged from $1.65
to $6 per dollar spent.88 However, the study advised that these positive results should be viewed
cautiously, as most programs were not evaluated scientifically rigorously and there was a possible bias
towards reporting positive results.89
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Privacy was also a chief concern, as employees supplied large amounts of healthcare data to
wellness programs, and some feared that there were not enough protections for employee data. This
created the potential that "it could be abused for workplace discrimination, credit screening or
marketing.”90
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There were also concerns that workplace wellness programs could actually increase employee
stress, thus backfiring and making employees less well. A group of researchers who conducted
analyses on the culture and history of wellness in the workplace stated that this occurred as “employees
ploughed a great deal of energy into trying to improve their health. Sometimes this meant that
employees had less time to focus on their core tasks. More frequently, these wellness initiatives would
eat into employees’ personal lives.”91
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Further, they cautioned that organizations could become too heavily focused on health and fitness,
creating cultures where relatively healthy people felt they could not fit in.92 A 2015 article in The
Economist noted how this cultural shift could be particularly difficult for CEOs and other organizational
leaders, who might be under more pressure to perform than the average employee. 93 This had caused
some to subscribe to intense fitness regimens or take medications that aided focus. The article stated,
“it is time to call a halt on all this hyperactivity, before it gets out of hand. There is no doubt that many
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bosses have heavy weights resting on their shoulders. But are they likely to make these decisions better
if they arrive at work exhausted and sleep-deprived?”94
Workplace wellness programs were continually evolving and many questions remained about their
future directions. One reviewer discussed the wide array of unknowns in the industry, stating:
…there is little insight offered on the proportion of funds to be spent on individual

counseling, biometric testing, exercise equipment, classes, subsidies for healthy food
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items, Web sites, advisory group meetings, personal trainers, on-site clinics, and
incentives, to name but a few program investment alternatives. More research is,
therefore, needed to better understand which of the above program components is most
cost-effective in providing value to workers, driving participation, and achieving specific
outcomes. In addition, research is needed to determine which program components are
most applicable for certain populations. For example, best practices found in a
manufacturing facility may not translate well to call centers, universities, or hospitals.95
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Mental Health Programs

According to the World Health Organization (WHO), there was “increasing evidence that both the
content and context of work can play a role in the development of mental health problems in the
workplace.” 96 For example, research showed that disengaged employees were more likely to have
health issues (e.g., stress, high blood pressure and depression) than engaged employees.97 The WHO
outlined several key workplace stress factors, including:
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• “Workload (both excessive or insufficient work);

• Lack of participation and control in the workplace;
• Monotonous or unpleasant tasks;
• Role ambiguity or conflict;
• Lack of recognition at work;
• Inequity;
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• Poor interpersonal relationships;

• Poor working conditions;
• Poor leadership and communication;
• Conflicting home and work demands.” 98
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Businesses often created or exacerbated employee health problems, especially those associated with
stress. For example, customer-facing personnel, such as call center workers, often suffered heavy stress
levels from dealing with difficult or unhappy customers.99 Further, there was increasing evidence that
senior executives were often overloaded and needed better time-management and stress-reduction.
McKinsey published research in 2016 which suggested that, even at organizations where health was
stated as a top priority, executive well-being suffered from high stress levels.100 Therefore, it was often
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important for senior executives to speak openly about their own stress challenges and how they
managed them.
Businesses endured many negative effects as a result of stress and the mental health challenges
among their employees. These included productivity losses, reputational risk, morale risk, and legal
costs.101 Though one study concluded that major depressive disorder (MDD) resulted in 27.2 lost work
days per affected employee, the authors found that it was presenteeism, and not absenteeism that had
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the greatest economic effect.102 Reputational risk was also a major concern for employers, as the media
discussed workplace-related mental health challenges more openly and frequently.103 Mental health
challenges posed a morale risk to the larger employee workforce, as an individual with a mental health
issue might act negatively towards or other employees or cause resentment if their work ethic faltered.
Finally, employers worried about the legal costs associated with mental health. In the U.S. in 2013,
mental disability claims of discrimination based on the Americans with Disabilities Act cost $25.5
million, with the largest number of claims based on depression, anxiety, and manic depressive
disorders.104 105
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Employers responded to these challenges by providing many different types of benefits to their
employees. Table 1 shows common ways that employees took to help employees manage their stress.
Table 1 Steps Taken by Employers to Manage Stress

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United States
Promotion of Employee Assistance Programs (EAP) 85%

Access to financial planning information/services 61%
Flexible working options 51%
Expanding EAP services and/or other stress management activities to dependents 46%
Education and awareness campaigns 40%
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Stress management interventions (e.g., stress management workshops, yoga, tai chi) 39%
Training for managers 34%
Specialized training for employees 23%
External specialist/resources used to design and deliver program(s) 23%
Risk assessments/stress audits 22%
Anti-stress space 10%
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Written guidelines on stress 7%
Source: “The Business Value of a Health Workfore: Staying@Work Survey Report 2013/2014, United States,” Towers Watson,
January 2014, http://www.towerswatson.com/en/Insights/IC-Types/Survey-Research-Results/2013/12/
stayingatwork-survey-report-2013-2014-us, accessed February 2014.
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Many corporations offered ways to effectively manage stress. For example, Johnson & Johnson
offered the Energy for Performance in Life program, which introduced the concept of managing
energy, not just time.106 It encouraged employees to put their energy into purposeful activity, which
included areas outside of work.
Other company-specific benefits
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While health insurance, workplace wellness programs, and mental health programs were common,
corporations often had to provide benefits that were specifically targeted to their employee populations
and their unique health challenges. For example, Anglo American, a global mining company, had
operations concentrated in Africa, where HIV/AIDs was a significant health challenge for employees
and their families. To combat the disease, the company paid for HIV/AIDs testing for their employees
and their family members. In 2011, it tested 92% of employees, up from 10% in 2003.107 In addition, the
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company also covered the cost of treatment for employees and their families and provided HIV/AIDs
education to entire villages where the company was located.108 The company took these actions because
it realized that its efforts needed to go beyond testing – for an infectious disease, the company had to
impact others in the community. It even provided its suppliers with incentives to test their employees
– often migrant workers – in the communities.
Anglo American was not the only company to address the health concerns of workers who were
not direct employees. Primark, a division of ABF, launched the HERproject in Bangladesh in 2011.109
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In partnership with NGOs and other global experts, the program focused on providing health care and
health education to female workers in garment factories.110 As of 2016, the program had provided
education on hygiene, sexual and reproductive health, maternal health and nutrition to over 5000
female factory workers in Bangladesh.111
After the program, there was an 89% increase in the number of women who used on-site or local
clinics to seek medical advice, 55% increase in those who used contraception, and a 98% increase in
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those who ate animal protein at least once a week.112 In addition, absenteeism and turnover decreased.
After these successes in Bangladesh, Primark expanded the program to China and Southern India with
the goal of eventually delivering improved health services and education to all women in its supply
chain.113
Similarly, Levi Strauss offered its subcontractors training programs for their workers on financial
literacy, health and nutrition, and acceptance and equality. Although workers took time off of
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production lines for the training, the programs increased both productivity and retention.114 Suppliers
who met Levi Strauss’s fair labor and environmental practice standards could qualify for low cost loans
(subsidized by Levi Strauss) from the International Finance Corporation.115
Wage Standards
By the late 2000’s, the relationship between wage level and health was well-documented. One group
of researchers reviewed a number of studies on this topic and found that people at the lowest
socioeconomic status across the world had higher death and illness rates “regardless of whether the
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major causes of death and disability were from infectious or noninfectious diseases and regardless of
how socioeconomic position was measured.”116 Another study found a significant relationship
between low wages and increased prevalence of obesity and increased body mass.117
By 2015, the minimum wage in the U.S. had become a contentious topic. The effects of raising the
minimum wage for the individual worker, companies, and the broader economy had been widely
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studied, but despite the focus on the topic, they remained fiercely debated. One of the most significant
questions was whether raising the minimum wage would lead employers to hire fewer workers, thus
increasing unemployment.118 Researchers with The Center for Economic and Policy conducted a
literature review on this topic and found that employment effects were consistently modest.119
However, research also supported those who argued for the other side. In a brief, researchers with The
Cato Institute stated, “a decision to increase the minimum wage is not cost-free; someone has to pay
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for it, and the research shows that low-skill youth pay for it by losing their jobs, while consumers may
also pay for it with higher prices.”120
Wage decisions were difficult for companies to make, and sometimes had unintended
consequences. In February, 2015, Wal-Mart Stores, Inc. (“Walmart”), a multi-national retail
corporation, announced that it would raise entry-level wages to at least $9/hour in 2015, and to
$10/hour in early 2016; wages for some manager roles would increase to $13/hour and $15/hour
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across the same time period.121 In October, 2015, Walmart stock fell after announcing at its annual
investor meeting that it expected a 6-12% decline in earnings per share in fiscal year 2017.122 The
disappointing results were attributed to the company’s investments in increasing wages and currency
exchange rates. 123 Charles Holley, Walmart’s executive vice president and chief financial officer stated:
Fiscal year 2017 will represent our heaviest investment period. Operating income is
expected to be impacted by approximately $1.5 billion from the second phase of our
previously announced investments in wages and training as well as our commitment to
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further developing a seamless customer experience…As a result of these investments, we
expect earnings per share to decline between 6 and 12 percent in fiscal year 2017, however
by fiscal year 2019 we would expect earnings per share to increase by approximately 5 to
10 percent compared to the prior year.124
Discussions around wage rates were not limited to the minimum wage. Dan Price, the founder and
CEO of Gravity Payments, a Seattle-based credit card processing company, made headlines in April
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2015 for his decision to increase the salaries of all his employees to a minimum of $70,000.125 To afford
the salary increases, he decided to cut his own salary from nearly $1 million a year to $70,000. His
decision was based on research that showed that salary increases, up to around $70,000, could make a
large difference in an individual’s happiness.126 Despite the initial positive attention the decision
garnered, there were several drawbacks. Though the company gained publicity and additional
customers, it also lost customers who found the salary decision political. Although many of the lower-
paid workers received salary bumps, the increases were more modest or nonexistent for higher-wage
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earners, and this factored into two of the company’s most valuable employees deciding to quit.127 Mr.
Price said “There’s no perfect way to do this and no way to handle complex workplace issues that
doesn’t have any downsides or trade-offs…I came up with the best solution I could.” 128
Company Structure and Culture

Many of the workplace factors that contributed to employee stress could be attributed to managerial
styles and team dynamics. Therefore, a company’s hierarchical structure and overarching culture could
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have far-reaching effects on employee engagement and mental health.
Zappos, an online shoe and retail company, gained media attention in 2015 when it abandoned its
traditional, hierarchical management structure and embraced a concept known as "holacracy.”
Holacracy “removes power from a management hierarchy and distributes it across clear roles, which
can then be executed autonomously.”129 At Zappos, employees joined voluntary groups, called
"circles," which were comprised of peers who not only helped with difficult projects, but also evaluated
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and rewarded other employees.130 When Zappos made the switch, it also offered employees a buyout
option for those who were not interested in participating in the new model; about 14% of the company’s
1600 employees left the company.131 CEO Tony Hsieh explained the reasoning for the new model,
stating:
Research shows that every time the size of a city doubles, innovation or productivity
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per resident increases by 15 percent. But when companies get bigger, innovation or
productivity per employee generally goes down. So we're trying to figure out how to
structure Zappos more like a city, and less like a bureaucratic corporation. In a city, people
and businesses are self-organizing. We're trying to do the same thing by switching from
a normal hierarchical structure to a system called Holacracy, which enables employees to
act more like entrepreneurs and self-direct their work instead of reporting to a manager
who tells them what to do.132
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Many companies also made cultural efforts to engage women in their workforces. According to the
WHO, women made up over 40% of the global labor force and on average earned two-thirds of the
income of men.133 Only 5% of Fortune 500 CEOs were women.134 Men and women often perceived
workplace stressors differently. A study in the United Kingdom concluded that “women are at risk of
increased depression and anxiety if the management style at their workplace is not inclusive or
considerate; and male employees are more at risk if they feel excluded from decision making.”135 136
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Representation of women in management varied widely by industry. For example, only 20% of
executives in the technology industry were women.137 A 2016 article published by The Vitality Institute
stated:
Of the women who are already working in technology, 27% report feeling as though
they are “stalled” in their job and that they are likely to leave within a year, a phenomenon
referred to as “a leaky pipeline”. So while getting women into the industry is a first step
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towards gender equity, creating a work environment that fosters their growth and
development will be equally important.138
Ernst & Young (“EY”), an international professional services and advisory firm, has focused on
accelerating women's progress in the workplace through its "Women. Fast forward" initiative. The
concept of the program was based on the finding that it would take 80 more years for gender parity in
the workplace.139 The company has both internal and external initiatives focused on advancing women
into leadership roles at a faster pace. As part of the program, EY surveyed 400 company leaders in
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EMEIA, Asia-Pacific and North America on engaging women in the workplace and produced a report
highlighting their findings. The report recommended three strategies for accelerating women in the
workforce:
1. Illuminate the path to leadership
2. Speed up company culture change with progressive company policy
3. Build supportive environments and work to eliminate conscious and unconscious bias140
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Due to the lack of female role models in C-suite leadership roles, the first recommendation was
focused on highlighting paths of advancement for women, as women could struggle to visualize
themselves in those roles. The second area focused on promoting work/life integration and flexibility
for women, who shouldered a greater amount of caretaking and housework than men, and the third
advocated for a supportive culture, stemming from the CEO downwards. 141
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Conclusion
The role of employers in employee health had evolved significantly over time. By 2016, some
employers had become stewards of health and wellness within their workforces, while others met
regulatory standards, but remained less involved overall. This note assessed the drivers behind
employer investments in employee health, as well as some of the benefits and drawbacks of employee
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health initiatives. However, several questions remained about the future of employee health.
Discussion Questions on Employee Health

1. Beyond legally mandated employee health standards, what responsibility do employers
have to provide a healthy environment for all employees?
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a. In a largely free market economy, employees are able to leave a work environment if
they feel another might be healthier for them. Is it therefore the responsibility of the
employer to provide a healthy environment, or should the responsibility sit with an
individual to find an environment that supports their own personal health priorities?
b. Research on individual choice in health care suggests that individuals do not always
make the best health decisions for themselves – even when they are educated on the
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health or financial risks at stake.142 Therefore, is some level of paternalism from
corporations or governments appropriate?
2. How should corporations balance the economic and social goals of investing in employee
health?
a. Many corporate investments in employee health are aimed at generating both

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corporate and social returns. Are both private and social returns likely from common
investments in employee health?
b. If positive social returns are generated more broadly, should governments subsidize
investments in employee health?
3. How should corporations consider the investment time horizon in employee health?
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a. Given that the potential benefits of employer investments in employee health may
outlast employee tenure at that employer, how should corporations prioritize shorter
and longer-term investments in employee health?
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Exhibit 1 US adults with two or more chronic conditions
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Source: Virginia M. Freid, M.S.; Amy B. Bernstein, Sc.D.; and Mary Ann Bush, M.S., “Multiple Chronic Conditions Among
Adults Aged 45 and Over: Trends Over the Past 10 Years,” CDC: NCHS DATA Brief, No. 100, July 2012, accessed at
http://www.cdc.gov/nchs/data/databriefs/db100.htm, accessed January 2016.
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No
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Exhibit 2 Penalties for Employers Not Offering Coverage Under the Affordable Care Act During
2016
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No
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Source: Kaiser Family Foundation, “Employer Responsibility Under the Affordable Care Act,” Kaiser Family Foundation,
October, 2, 2015, http://kff.org/infographic/employer-responsibility-under-the-affordable-care-act/, accessed
October, 2015.
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Exhibit 3 Average Premium Increases for Covered Workers with Family Coverage, 2000-2015
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Source: The Kaiser Family Foundation and Health Research & Educational Trust, ”Employer Health Benefits: 2015 Summary
Findings,” September 22, 2015, http://kff.org/health-costs/report/2015-employer-health-benefits-survey/, accessed
October, 2015.
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No
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Exhibit 4 Number and rate of fatal occupational injuries by industry sector, 2014
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Source: Bureau of Labor Statistics, “Number and rate of fatal occupational injuries by industry sector, 2014*,"
http://www.bls.gov/iif/oshwc/cfoi/cfch0013.pdf, accessed October, 2015.
No
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Exhibit 5 Percentage of Covered Workers Enrolled in an HDHP/HRA or HSA-Qualified HDHP,
2006-2015
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Source: The Kaiser Family Foundation and Health Research & Educational Trust, ”Employer Health Benefits: 2015 Summary
Findings,” September 22, 2015, http://kff.org/health-costs/report/2015-employer-health-benefits-survey/, accessed
October, 2015.
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No
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Endnotes
1 Aaron Smith, “Amazon is America's best company. Says who? You!,” CNN Money, June 15, 2015,
http://money.cnn.com/2015/06/15/news/companies/amazon-reputation/index.html, accessed October, 2015.
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2 Jodi Kantor and David Streitfeld, “Inside Amazon: Wrestling Big Ideas In a Bruising Workplace,” The New York Times,
August, 15, 2015, http://www.nytimes.com/2015/08/16/technology/inside-amazon-wrestling-big-ideas-in-a-bruising-
workplace.html, accessed October, 2015.
3 The New York Times, “Depiction of Amazon Stirs a Debate About Work Culture,” The New York Times, August 18, 2015,
http://www.nytimes.com/2015/08/19/technology/amazon-workplace-reactions-comments.html, accessed October, 2015.
4 Ibid.
5 Harvard Business Review Staff, “The Best-Performing CEOs in the World,” Harvard Business Review November 2015 issue (pg.
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49-59), https://hbr.org/2015/11/the-best-performing-ceos-in-the-world, accessed October, 2015.
6 Ibid.
7 TE, Kottke, M Stiefel, NP Pronk, “’Well-Being in All Policies’: Promoting Cross-Sectoral Collaboration to Improve People’s
Lives,” Prev Chronic Dis 2016;13:160155. DOI: http://dx.doi.org/10.5888/pcd13.160155
8 Lydia Saad, “The "40-Hour" Workweek Is Actually Longer -- by Seven Hours,” Gallup Poll website post, August 29, 2014,
http://www.gallup.com/poll/175286/hour-workweek-actually-longer-seven-hours.aspx, accessed October, 2015.
9 World Health Organization, “Nutrition: Background,” WHO website,
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http://www.who.int/nutrition/topics/2_background/en/, accessed November 2015.
10 The Vitality Institute, “Investing in Prevention: A National Imperative,” June, 2014, http://thevitalityinstitute.org/site/wp-
content/uploads/2014/06/Vitality_Recommendations2014.pdf, accessed May 2016.
11 NIMH, “The Numbers Count: Mental Disorders in America,” http://www.nimh.nih.gov/health/publications/the-
numbers-count-mental-disorders-in-america/index.shtml#Intro, accessed July 2014.
12 John A. Quelch and Carin-Isabel Knoop, “Mental Health and the American Workplace” HBS No. 9-515-062 (Boston:
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Harvard
Business School Publishing, 2015), pg. 2.
13 Fredric Blavin, Bowen Garrett, Linda Blumberg, Matthew Buettgens, Sarah Gadsden and Shanna Rifkin, “Monitoring the
Impact of the Affordable Care Act on Employers,” The Urban Institute, October 2014,
http://www.urban.org/sites/default/files/alfresco/publication-pdfs/413273-Monitoring-the-Impact-of-the-Affordable-Care-
Act-on-Employers.PDF, accessed October, 2015.
14 Ibid
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15 Kaiser Family Foundation, “Employer Responsibility Under the Affordable Care Act,” October, 2, 2015,
http://kff.org/infographic/employer-responsibility-under-the-affordable-care-act/, accessed October 2015.
16 Karen Pollitz and Matthew Rae, “Workplace Wellness Programs Characteristics and Requirements,” The Kaiser Family
Foundation, June 15, 2015, http://kff.org/private-insurance/issue-brief/workplace-wellness-programs-characteristics-and-
requirements/, accessed October, 2015.
17 Ibid.
18 CDC, “Workplace Health Promotion: Glossary Terms,”

http://www.cdc.gov/workplacehealthpromotion/glossary/index.html#A2, accessed October, 2015.
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19 Ibid
20 Thomas Parry and Bruce Sherman, “Workforce Health – The Transition from Costs to Outcomes to Business Performance,”
Benefits Quarterly first quarter 2015, http://www.ifebp.org/inforequest/ifebp/0166489.pdf, accessed October, 2015.
22
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21 Bruce Japsen, “U.S. Workforce Illness Costs $576B Annually From Sick Days To Workers Compensation,” Forbes, September
12, 2012, http://www.forbes.com/sites/brucejapsen/2012/09/12/u-s-workforce-illness-costs-576b-annually-from-sick-days-
to-workers-compensation/#3ea7d8cf7256, accessed May 2016.
22 Howard G. Birnbaum, et al., “Employer Burden of Mild, Moderate, and Severe Major Depressive Disorder: Mental Health
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Services Utilization and Costs, and Work Performance," Depression and Anxiety 27: 78-89 (2010).
23 Thomas C. Buchmueller and Alan C. Monheit, “EMPLOYER-SPONSORED HEALTH INSURANCE AND THE PROMISE
OF HEALTH INSURANCE REFORM,” The National Bureau of Economic Research, April 2009,
http://www.nber.org/papers/w14839.pdf, accessed October, 2015.
24 Ibid.
25 The Kaiser Family Foundation and Health Research & Educational Trust, ”Employer Health Benefits: 2015 Summary
Findings,” September 22, 2015, http://kff.org/health-costs/report/2015-employer-health-benefits-survey/, accessed October,
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2015.
26 Ibid.
27 Zeynep Ton, “The Good Jobs Strategy,” Houghton Mifflin Harcourt Publishing Company, New York, New York, 2014, pg. 64-
67.
28 Ibid.
29 Thomas Parry and Bruce Sherman, “Workforce Health – The Transition from Costs to Outcomes to Business Performance,”
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Benefits Quarterly first quarter 2015, http://www.ifebp.org/inforequest/ifebp/0166489.pdf, accessed October, 2015.
30 Fortune, “100 Best Companies to Work For,” Fortune website, http://fortune.com/best-companies/, accessed October,
2015.
31 Zeynep Ton, “The Good Jobs Strategy,” Houghton Mifflin Harcourt Publishing Company, New York, New York, 2014, pg. 67.
32 Elias G. Rizkallah, “Brand-Consumer Relationship And Corporate Social Responsibility: Myth Or Reality & Do Consumers
Really Care?,” Journal of Business and Economics Research, June 2012, Vol. 10 No. 6.
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33 Elias G. Rizkallah, “Brand-Consumer Relationship And Corporate Social Responsibility: Myth Or Reality & Do Consumers
Really Care?,” Journal of Business and Economics Research, June 2012, Vol. 10 No. 6.
34National Labor Relations Board, “The 1935 passage of the Wagner Act,” https://www.nlrb.gov/who-we-are/our-
history/1935-passage-wagner-act, accessed October, 2015.
35 Bureau of Labor Statistics, “Union Members Summary,” Bureau of Labor Statistics Economic Summary,
http://www.bls.gov/news.release/union2.nr0.htm, accessed October, 2015.
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36 Ibid.
37 Pete Wells, “Danny Meyer Restaurants to Eliminate Tipping,” New York Times, October 14, 2015,
http://www.nytimes.com/2015/10/15/dining/danny-meyer-restaurants-no-tips.html?_r=0
38 Ibid.
39 United States Department of Labor, “Progressive Ideas,” http://www.dol.gov/dol/aboutdol/history/mono-

regsafepart06.htm, accessed October, 2015.
40 Ibid.
41 OSHA, “OSHA Celebrates 40 years of accomplishments in the Workplace,”

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https://www.osha.gov/osha40/OSHATimeline.pdf, accessed October, 2015.

42The National Institute for Occupational Safety and Health (NIOSH), “About NIOSH,”
http://www.cdc.gov/niosh/about.html, accessed October, 2015.
43 Occupational Safety and Health Review Commission, “About the Commission,” http://www.oshrc.gov/, accessed October,
2015.
44 John A. Quelch and Margaret L. Rodriguez, “Rana Plaza (C): Primark and Victim Compensation” HBS No. 9-516-014
(Boston: Harvard Business School Publishing, 2015).
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45 JULFIKAR ALI MANIK and NIDA NAJAR, “Bangladesh Police Charge 41 With Murder Over Rana Plaza Collapse,” The
New York Times, June 1st, 2015, http://www.nytimes.com/2015/06/02/world/asia/bangladesh-rana-plaza-murder-
charges.html, accessed October, 2015.
46 John A. Quelch and Margaret L. Rodriguez, “Rana Plaza (C): Primark and Victim Compensation” HBS No. 9-516-014
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(Boston: Harvard Business School Publishing, 2015).
47 Primark, “Rana Plaza,” Primark website, http://www.primark.com/en/our-ethics/news/rana-plaza, accessed October, 2015.
48 Bureau of Labor Statistics, “EMPLOYER COSTS FOR EMPLOYEE COMPENSATION – JUNE 2015,” News Release,
September 9th, 2015, http://www.bls.gov/news.release/pdf/ecec.pdf, accessed October, 2015.
49 Taylor Lorenz, “Startups Offer So Many Extravagant Perks, They Have Begun Hiring People Just To Manage It All,”
November, 25, 2014, http://www.businessinsider.com/startups-offer-so-many-extravagant-perks-they-have-begun-hiring-
people-just-to-manage-it-all-2014-11, accessed May, 2016.
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50 Ibid.
51 Drake Baer, “Here's What Google Teaches Employees In Its 'Search Inside Yourself' Course,” Business Insider, August 5,
2014, http://www.businessinsider.com/search-inside-yourself-googles-life-changing-mindfulness-course-2014-8, accessed
May, 2016.
52 Julie Bort, This Google engineer’s title is 'Jolly Good Fellow' and he’s solving unhappiness and war,” Business Insider,
September 18th, 2015. http://www.businessinsider.com/google-jolly-good-fellow-chade-meng-tan-2015-9
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53 The Guardian, “Google's head of mindfulness: 'goodness is good for business',” http://www.theguardian.com/sustainable-
business/google-meditation-mindfulness-technology, accessed October, 2015.
54 Ibid.
55 The Kaiser Family Foundation and Health Research & Educational Trust,” Employer Health Benefits: 2015 Summary
2015.
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2015.
57 Katherine Baicker and Amitabh Chandra, “The Veiled Economics of Employee Cost Sharing,” JAMA Internal Medicine, May
2015, Vol. 175, no.7, pp 1081-2.
58 Katherine Baicker and Amitabh Chandra, “The Veiled Economics of Employee Cost Sharing,” JAMA Internal Medicine, July
2015, Vol. 175, no.7, pp 1081-2.
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59 The Kaiser Family Foundation and Health Research & Educational Trust,” Employer Health Benefits: 2015 Summary
2015.
60 Ibid.
61 Ibid.
62 Zarek C. Brot-Goldberg, Amitabh Chandra, Benjamin R. Handel, Jonathan T. Kolstad, “What Does a Deductible Do? The
Impact of Cost-Sharing on Health Care Prices, Quantities, and Spending Dynamics,” the National Bureau of Economic Research,
October 2015, NBER Working Paper No. 21632, accessed at http://www.nber.org/papers/w21632, accessed January, 2016.
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63 Ibid.
64 Ibid.
65 Katherine Baicker and Amitabh Chandra, “The Veiled Economics of Employee Cost Sharing,” JAMA Internal Medicine, May
2015, Vol. 175, no.7, pp 1081-2.
66 Ibid.
67 Ibid.
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68 IRS, “Questions and Answers on Employer Shared Responsibility Provisions Under the Affordable Care Act,”
https://www.irs.gov/Affordable-Care-Act/Employers/Questions-and-Answers-on-Employer-Shared-Responsibility-
Provisions-Under-the-Affordable-Care-Act, accessed October, 2015.
69 HIROKO TABUCHI, “Walmart to End Health Coverage for 30,000 Part-Time Workers,” The New York Times, October, 7th,
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2014, http://www.nytimes.com/2014/10/08/business/30000-lose-health-care-coverage-at-walmart.html, accessed October,
2015.
70 Sally Welborn, “Providing Quality Health Benefits for Our Associates,” Walmart Today blog, Walmart website,
http://blog.walmart.com/business/20141007/providing-quality-health-benefits-for-our-associates, accessed October, 2015.
71 HIROKO TABUCHI, “Walmart to End Health Coverage for 30,000 Part-Time Workers,” The New York Times, October, 7th,
2014, http://www.nytimes.com/2014/10/08/business/30000-lose-health-care-coverage-at-walmart.html, accessed October,
2015.
yo
72 Sally Welborn, “Providing Quality Health Benefits for Our Associates,” Walmart Today blog, Walmart website,
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2015.
74 Soeren Mattke, Christopher Schnyer, Kristin R. Van Busum, “A Review of the U.S. Workplace Wellness Market, RAND
CORPORATION, 2012, pg. 5, accessed at http://www.dol.gov/ebsa/pdf/workplacewellnessmarketreview2012.pdf, accessed
op
October, 2015.
75 RAND Corporation, “Do Workplace Wellness Programs Save Money?” 2014,
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2015.
76 Rachel Emma Silverman, “Genetic Testing May Be Coming to Your Office,” The Wall Street Journal, December 15th, 2015,
accessed at http://www.wsj.com/articles/genetic-testing-may-be-coming-to-your-office-1450227295, accessed January, 2016.
77Soeren Mattke, Kandice Kapinos, John P. Caloyeras, Erin Audrey Taylor, Benjamin Batorsky, Hangsheng Liu, Kristin R. Van,
tC
Busum, Sydne Newberry, “Workplace Wellness Programs Services Offered, Participation, and Incentives,” RAND Corporation,
2014, https://www.dol.gov/ebsa/pdf/WellnessStudyFinal.pdf, accessed October, 2015.
78 Hector De La TorreRon Goetzel, “From Evidence to Practice: Workplace Wellness that Works,” Harvard Business Review,
Septmeber, 2015, https://hbr.org/2016/03/how-to-design-a-corporate-wellness-plan-that-actually-works, accessed May, 2016.
79 Rebecca Greenfield, “Employee Wellness Programs Not So Voluntary Anymore,” Bloomberg Business, January 15th, 2016,
accessed at http://www.bloomberg.com/news/articles/2016-01-15/employee-wellness-programs-not-so-voluntary-
anymore?utm_source=hs_email&utm_medium=email&utm_content=25343526&_hsenc=p2ANqtz--
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80 Ibid.
81 Ibid.
82 John A. Quelch and Carin-Isabel Knoop, “Johnson & Johnson: The Promotion of Wellness,” HBS No. 9-514-112 (Boston:
Harvard Business School Publishing, 2014).
Do
84 Ronald J. Ozminkowski, et al., “Long-Term Impact of Johnson & Johnson’s Health & Wellness Program on Health Care
Utilization and Expenditures,” Journal of Occupational and Environmental Medicine, Vol. 44, No. 1, 2002,
http://www.thehealthproject.com/documents/2003/johnson_johnson_utilization_expenditure.pdf, accessed January 2014.
85 Rachel M. Henke, Ron Z. Goetzel, Janice McHugh, and Fik Isaac, “Recent Experience in Health Promotion at Johnson &
Johnson: Lower Health Spending, Strong Return On Investment,” Health Affairs 30:3, March 2011, via ProQuest Business
Collection, accessed January 2014.
25
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os
86 Rachel M. Henke, Ron Z. Goetzel, Janice McHugh, and Fik Isaac, “Recent Experience in Health Promotion at Johnson &
Johnson: Lower Health Spending, Strong Return On Investment,” Health Affairs 30:3, March 2011, via ProQuest Business
Collection, accessed January 2014.
rP
88 Soeren Mattke, Christopher Schnyer, Kristin R. Van Busum, “A Review of the U.S. Workplace Wellness Market,” RAND
Corporation, 2012, http://www.dol.gov/ebsa/pdf/workplacewellnessmarketreview2012.pdf, accessed October, 2015.
89 Ibid.
90 Jay Hancock and Julie Appleby, “7 Questions To Ask Your Employer About Wellness Privacy,” Kaiser Health News, September,
30, 2015, http://khn.org/news/7-questions-to-ask-your-employer-about-wellness-privacy/, accessed October, 2015.
yo
91 Scott Berinato, “Corporate Wellness Programs Make Us Unwell: An Interview with André Spicer,” Harvard Business Review
May 2015 issue (pg. 28-29), https://hbr.org/2015/05/corporate-wellness-programs-make-us-unwell, accessed October, 2015.
92 Ibid.
93 The Economist, “Here comes SuperBoss,” The Economist: Schumpeter,” December, 19th, 2015,
http://www.economist.com/news/business/21684107-cult-extreme-physical-endurance-taking-root-among-executives-here-
comes-superboss, accessed January, 2016.
94 Ibid.
op
95 RZ Goetzel, Henke RM, Tabrizi M, Pelletier KR, Loeppke R, Ballard DW, Grossmeier J, Anderson DR, Yach D, Kelly RK,
McCalister T, Serxner S, Selecky C, Shallenberger LG, Fries JF, Baase C, Isaac F, Crighton KA, Wald P, Exum E, Shurney D,
Metz RD, “Do workplace health promotion (wellness) programs work?,” Journal of Occupational and Environmental
Medicine, 2014 Sep: 56(9):927-34. doi: 10.1097/JOM.0000000000000276.
96 World Health Organization, “MENTAL HEALTH POLICIES AND PROGRAMMES IN THE WORKPLACE,” 2005, p. 2,
http://www.who.int/mental_health/policy/workplace_policy_programmes.pdf, accessed January 6, 2014.
tC
97 Jim Harter and Amy Adkins, “Engaged Employees Less Likely to Have Health Problems,” Gallup, DECEMBER 18, 2015,
http://www.gallup.com/poll/187865/engaged-employees-less-likely-health-problems.aspx?utm_source=alert&utm_
medium=email&utm_content=morelink&utm_campaign=syndication, accessed May, 2016.
98 World Health Organization, “MENTAL HEALTH POLICIES AND PROGRAMMES IN THE WORKPLACE,” 2005, p. 2,
http://www.who.int/mental_health/policy/workplace_policy_programmes.pdf, accessed January 6, 2014.
99 Talkdesk, “8 Stress Management Techniques for Call Center Agents,” talkdesk blog, https://www.talkdesk.com/blog/8-
stress-management-techniques-for-call-center-agents/, accessed May, 2016.
No
100 Manish Chopra, “Want to be a better leader? Observe more and react less,” McKinsey Quarterly, February 2016,
http://www.mckinsey.com/global-themes/leadership/want-to-be-a-better-leader-observe-more-and-react-less?cid=other-
eml-nsl-mip-mck-oth-1603, accessed May, 2016.
102 Howard G. Birnbaum, et al., “Employer Burden of Mild, Moderate, and Severe Major Depressive Disorder: Mental Health
Services Utilization and Costs, and Work Performance," Depression and Anxiety 27: 78-89 (2010).
103 Nicholas Kristof, “First Up, Mental Illness. Next Topic Is Up to You,” The New York Times, http://www.nytimes.com/
2014/01/05/opinion/sunday/kristof-first-up-mental-illness-next-topic-is-up-to-you.html?_r=0, accessed February 2014.
Do
104 U.S. Equal Employment Opportunity Commission, “ADA Charge Data – Monetary Benefits FY 1997 – FY 2013,”
http://www.eeoc.gov/eeoc/statistics/enforcement/ada-monetary.cfm, accessed February 2014.
106 Johnson & Johnson, “Energizing Performance,” JnJ website, http://www.jnj.com/caring/citizenship-sustainability/our-
engagements/energizing-performance, accessed May, 2016.
26
t
os
107 AngloAmerican, “HIV/AIDS Fact Sheet,” November, 2012, http://www.angloamerican.com/~/media/Files/A/Anglo-
American-Plc/pdf/development/AngloAmerican_HIV_2012.pdf, accessed May, 2016.
108 AngloAmerican, “HIV/AIDS Fact Sheet,” November, 2012, http://www.angloamerican.com/~/media/Files/A/Anglo-
American-Plc/pdf/development/AngloAmerican_HIV_2012.pdf, accessed May, 2016.
rP
109 Primark, “Programmes: The HERproject,” Primark website, http://www.primark-bangladesh.com/our-work-in-
bangladesh/, accessed May, 2016.
110 Ibid.
111 Ibid.
112 Ibid.
yo
113 Ibid.
114 Reuters, “The World Bank Group’s International Finance Corporation and Levi Strauss & Co. Reward Garment Suppliers
for Stronger Labor, Environment, Health and Safety Performance,” Reauters, November 4, 2014,
http://www.reuters.com/article/ca-levi-strauss-ifc-idUSnBw045320a+100+BSW20141104, accessed May, 2016.
115 Ibid.
116George Kaplan, Mary Haan, S. Leonard Syme, Meredith Minkler, and Marilyn Winkleby, “Socioeconomic status and
health,” accessed online at http://www.researchgate.net/profile/George_Kaplan2/publication/30856094_Socioeconomic_
op
status_and_health/links/0fcfd5138d9995a6fb000000.pdf, accessed October, 2015.
117 D. Kim and JP Leigh, “Estimating the effects of wages on obesity,” Journal of Occupational Environmental Medicine, 2010 May,
52(5):495-500.
118 John Schmitt, “Why Does the Minimum Wage Have No Discernible Effect on Employment?,” Center for Economic and Policy
Research, February 2013, accessed at
http://www.cepr.net/documents/publications/min-wage-2013-02.pdf, accessed October, 2015.
tC
119 Ibid.
120 Mark Wilson, “The Negative Effects of Minimum Wage Laws,” Cato Institute, June 2012, accessed at
http://object.cato.org/sites/cato.org/files/pubs/pdf/PA701.pdf, accessed October, 2015.
121 Doug McMillon, “In Letter to Associates, Walmart CEO Doug McMillon Announces Higher Pay,” Walmart Today blog,
February 15, 2015, Walmart website, http://blog.walmart.com/in-letter-to-associates-walmart-ceo-doug-mcmillon-announces-
higher-pay, accessed October, 2015.
122 Lauren Gensler, “Wal-Mart's A Wreck: Stock Suffers Worst Loss In 15 Years On Dim Outlook,” Forbes, October, 14th, 2015,
No
http://www.forbes.com/sites/laurengensler/2015/10/14/wal-marts-stock-plunges-on-dim-outlook/, accessed October,

2015.
123 Ibid.
124 Walmart, “Walmart strategy drives growth and sustainable returns, Plans $20 billion share repurchase program over two
years,” SEC Document October, 2015, https://www.sec.gov/Archives/edgar/data/104169/000010416915000049/exhibit991-
10142015.htm, accessed October, 2015
125 Charles Rile and Poppy Harlow, “Gravity Payments CEO defends $70,000 minimum salary,” CNN Money, August 10th,
2015, http://money.cnn.com/2015/08/09/news/gravity-payments-dan-price-70k-salary/, accessed October, 2015.
126 Ibid.
Do
127 Patricia Cohen, “A Company Copes with Backlash Aginast the Raise that Roared,” The New York Times, July 31st, 2015,
http://www.nytimes.com/2015/08/02/business/a-company-copes-with-backlash-against-the-raise-that-roared.html,
accessed October, 2015
128 Ibid.
129 Holacracy, “How it Works,” Holacracy.org website, http://www.holacracy.org/how-it-works/, accessed October, 2015.
27
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130 Yuki Noguchi, “Zappos: A Workplace Where No One And Everyone Is The Boss,” NPR, July, 21st, 2015,
http://www.npr.org/2015/07/21/421148128/zappos-a-workplace-where-no-one-and-everyone-is-the-boss, accessed October,
2015.
131 Ibid.
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132 Zappos, “Holacracy and Self-Organization,” Zappos company website, http://www.zapposinsights.com/about/holacracy,
accessed October, 2015.
133 World Health Organization, “MENTAL HEALTH POLICIES AND PROGRAMMES IN THE WORKPLACE,” 2005,
http://www.who.int/mental_health/policy/workplace_policy_programmes.pdf, accessed October, 2015.
134 EY, “Women. Fast Forward.” EY website, PDF publication, http://www.ey.com/Publication/vwLUAssets/ey-women-fast-
forward-thought-leadership/$FILE/ey-women-fast-forward-thought-leadership.pdf, accessed October, 2015.
yo
135 Linda Seymour, Sainsbury Centre for Mental Health, “Common mental health problems at work,” June 2010, p. 4,
http://www.centreformentalhealth.org.uk/pdfs/BOHRF_common_mental_health_problems_at_work.pdf, accessed January
7, 2014.
137 Gabriela Seplovich and Sarah Kunkle, “The Gender Divide in Tech: A Leaky Pipeline,” The Vitality Institute, February 23,
2016, http://thevitalityinstitute.org/gender-divide-tech-leaky-pipeline/, accessed May, 2016.
op
138 Ibid.
139 EY, “Women. Fast Forward,” EY company website, Women. Fast Forward. Website,
http://www.ey.com/GL/en/Issues/Business-environment/women-fast-forward, accessed October, 2015.
140 EY, “Women. Fast Forward.” EY company website, PDF publication, http://www.ey.com/Publication/vwLUAssets/ey-
women-fast-forward-thought-leadership/$FILE/ey-women-fast-forward-thought-leadership.pdf, accessed October, 2015.
141 Ibid.
tC
142 David A. Asch, MDKevin G. Volpp, MD, “Use Behavioral Economics to Achieve Wellness Goals,” December 1, 2014,
Harvard Business Review, https://hbr.org/2014/12/use-behavioral-economics-to-achieve-wellness-goals, accessed January,
2016.
No
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Health at Work

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Why Employers Invest in Employee Health

4. Promoting brand reputation

5. Complying with union agreements

6. Addressing a moral imperative

additional incentives for “health-contingent” wellness programs.16 Health-contingent wellness

How Employers Promote Employee Health

Employee Benefit Programs

Workplace Wellness Programs

Broadly, a workplace wellness program is an employment-based activity or employer

combination of data collection on employee health risks and population-based strategies

1. Unknown or lack of impact

2. Inadequate protection of employee privacy

3. Creation of a toxic or competitive workplace culture

…there is little insight offered on the proportion of funds to be spent on individual

Mental Health Programs

• “Workload (both excessive or insufficient work);

• Poor interpersonal relationships;

Table 1 Steps Taken by Employers to Manage Stress

Promotion of Employee Assistance Programs (EAP) 85%

Written guidelines on stress 7%

Other company-specific benefits

Company Structure and Culture

have far-reaching effects on employee engagement and mental health.

1. Illuminate the path to leadership

2. Speed up company culture change with progressive company policy

Discussion Questions on Employee Health

a. Many corporate investments in employee health are aimed at generating both

18 CDC, “Workplace Health Promotion: Glossary Terms,”

39 United States Department of Labor, “Progressive Ideas,” http://www.dol.gov/dol/aboutdol/history/mono-

41 OSHA, “OSHA Celebrates 40 years of accomplishments in the Workplace,”

https://www.osha.gov/osha40/OSHATimeline.pdf, accessed October, 2015.

http://www.forbes.com/sites/laurengensler/2015/10/14/wal-marts-stock-plunges-on-dim-outlook/, accessed October,

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