The latest buzzword in managing health care costs is "wellness"-- programs that emphasize prevention and personal accountability. Nassau County, New York, for instance, hopes to save $4 million through a wellness initiative for employees. State associations, such as the North Carolina League of Municipalities, are expanding their employee assistance programs to include voluntary wellness counseling and support programs.

Many wellness efforts began as voluntary initiatives, included in the health care services package offered to employees. But now there is a new twist. What had been just a "carrot" is becoming a "stick."

For some public employees and retirees, the downside of the movement is higher insurance premiums for those who don't "live right." Employers are likely to favor the cost-sharing implications of charging those whose lifestyles result in higher medical costs. Employees and their representatives are likely to balk. The problem is where to draw the line--especially if the penalty for an undesirable lifestyle leads to exclusion from coverage.

Should firefighters be forbidden to smoke, in light of the occupational hazards that their jobs entail? Should cities set weight limits on police officers? What about body-mass-index-based insurance premiums for overweight office workers whose job performance is unaffected by their obesity but whose medical costs are arguably higher? Just as we have seen lawsuits over pre-employment testing of job candidates, we will see court decisions that determine the boundaries for employment wellness programs.

Public-sector managers and policy makers might be wise to tread a fine line here, and be careful to treat their employees as partners, not as cattle.