I am troubled on many levels by themes in this article from The New York Times: The concept that individuals need to be incentivized with cash for taking care of themselves is perverse. Those who care about their health should need no incentive to take care of themselves on an ongoing basis. And the notion that employers must bear the burden of flagrantly poor health choices of their employees appears to underlie employers taking on the creation of incentives to change.

In the US, it is illegal to discriminate in hiring on the basis of a number of attributes, most of which are out of the control of the individual, such as age, gender and national origin. But employers discriminate regularly on the basis of past experience, academic standing and accomplishment, interviews, references and many other factors, some of which—but not all— may be under the direct control of the applicant, or at least flow from choices made at the application process or over time. Employers make no apology for such discrimination and applicants expect to be measured on many qualities.

Is an employer well served who ignores or downplays choices of prospective employees that increase their health risks? Is there a correlation on work quality and employment costs that can be observed among employees who engage at the time of hiring in fewer risky health behaviors? And what is the actual success rate of employer incentives, “wellness” programs (the trendy word “wellness” itself is in dire need of its own rehab – “health” would suffice), in creating long term results and change?

What would be the impact of employers making hiring decisions in part based upon legal discriminators that are health related, such as smoking, physical fitness appropriate to age and other factors. We tell our children to get a good education to increase their chances of successful employment, and this is strong incentive for study. Were there similarly explicit conversations about the relative employability of individuals based upon their physical lifestyle choices, might it have a positive social impact on the health of society overall?

Our declining health status and dramatic increases in chronic diseases relating to lifestyle—such as Type 2 diabetes—is creating billions in expense and much human tragedy. Society’s conversation on who bears the responsibility for health and the cost of health is one that must continue.