The two biggest contributors that plague local government employee health care costs — obesity and smoking — are arguably the most preventable. In response, cities and counties are developing in-house wellness programs that improve employee health and the bottom line.

Since Jan. 1, 2002, the Tacoma-Pierce County, Wash., Health Department has been requiring prospective employees to sign a contract in which they agree to be non-smokers on and off the job as a condition of employment. By signing the contract, individuals acknowledge that employers spend an average of $753 per year more in medical costs for a smoker than a non-smoker. Employees who smoked before the policy was implemented are exempt, but they are offered educational materials on tobacco use and resources to help them quit.

Orange County, Fla., does not prohibit employees from smoking, but it instituted a 12-week voluntary wellness program in 2003 that encouraged smokers to quit and others to lose weight. The three-month program costs $30,000 to implement and is funded by the county, which has 6,600 employees. In the first year, 20 percent of all employees participated by tracking fruit and vegetable servings, water consumption and exercise. Employees also attended health classes and underwent health screenings before and after the program. In total, employees shed 2,226 pounds. The initiative was repeated in 2004, and another 2,503 pounds melted away with the same level of participation.

Many employees quit smoking during the program but picked up the habit again when it was over, says Erlene Cavalere, county wellness coordinator. The same held true for diet and exercise. As a result, the county is developing a permanent, year-round program to address employee health issues. “We are in the process of determining what exactly we can require of employees,” says Cavalere, who predicts that as more obesity research is conducted and made public, employers will be able to request more lifestyle modification. In states that have “lifestyle discrimination” statutes that prohibit discrimination based on smoking, obesity and even alcohol abuse, however, wellness programs likely will remain voluntary.

Like Orange County, Martin County, Fla., began a wellness program in 2000 that included an onsite lunchtime Weight Watchers group and other health prevention incentives, such as a payroll deduction for gym memberships and onsite health screenings. Benefits Coordinator Joann Donase says of the 1,000 employees in the county's insurance program, more than 300 participated in the annual health physicals in which a mobile lab provides blood tests and ultrasounds. Employees pay a $20 co-pay, and test results are mailed to their homes.

The health checkups were combined with a safety education program in an annual fair last year. “If you can stop people from being sick or from hurting themselves, you can keep the insurance down,” Donase says.

Catawba County, N.C., with 1,000 employees, opened an employee walk-in medical clinic in 2002. The clinic costs $8,000 per month to operate, and is paid for out of the county's self-insurance budget. For a $5 co-pay, employees may visit the clinic during office hours. For wellness visits, they pay nothing. “Our doctor visit costs have gone down 44 percent,” says Debbie Bradley, county personnel director.

Bradley says the clinic has saved lives and, instead of taking off a half-day for doctor's appointments, employees can receive medical treatment onsite in 15 minutes to 20 minutes. “It's a win-win for everyone,” she says.