An underlying premise of the Affordable Care Act provisions that encourage employers to adopt health promotion programs is an association between workers' modifiable health risks and increased health care costs. Employers, consultants, and vendors have cited riskcost estimates developed in the 1990s and wondered whether they still hold true. Examining ten of these common health risk factors in a working population, we found that similar relationships between such risks and total medical costs documented in a widely cited study published in 1998 still hold. Based on our sample of 92,486 employees at seven organizations over an average of three years, $82,072,456, or 22.4 percent, of the $366,373,301 spent annually by the seven employers and their employees in the study was attributed to the ten risk factors studied. This amount was similar to almost a quarter of spending linked to risk factors (24.9 percent) in the 1998 study. High risk for depression remained most strongly associated with increased per capita annual medical spending (48 percent, or $2,184, higher). High blood glucose, high blood pressure, and obesity were strongly related to increased health care costs (31.8 percent, 31.6 percent, and 27.4 percent higher, respectively), as were tobacco use, physical inactivity, and high stress. These findings indicate ongoing opportunities for well-designed and properly targeted employer-sponsored health promotion programs to produce substantial savings. S ection 4303 of the Affordable Care Act of 2010 and section 2705 of the Public Health Service Act of 1944, which was amended by the Affordable Care Act, contain provisions that encourage employers to adopt health promotion and risk reduction programs, also known as employee wellness programs. An underlying premise of these provisions is that modifiable health risks, such as obesity and high blood pressure, are associated with increased health care costs in the employed population. Therefore, employers that undertake risk-reduction programs may save on health care expenditures.The largest employer-based study that supported the association between higher health risks and higher costs used data that are now seventeen years old. Also, both personal health behavior and health care services have changed over time. We therefore revisited this pivotal assumption using more current data. In doing so, we demonstrated that the relationships shown more than a decade ago between employee health risks and subsequent total health care costs still hold today. These enduring rela- tionships continue to indicate the potential to reduce health care spending by putting in place evidence-based health promotion programs.

This 7-year evaluation, with high participation and large sample size, provides robust estimates of health improvements that can be achieved through a voluntary incentive-based wellness program.