IRVING, Texas - On his 21st day back at work after a heart attack and triple bypass surgery, Chris Zubko received a call from the main office. Through an app on his phone, his boss was literally monitoring every step of Zubko's recovery.
"Man! I noticed your steps have picked up,'' gushed Wayne Gono, 65, whose family operates Regal Plastics, a small fabrication business with satellite shops around Texas. "You used to be under 2,000, now you're over 6,000. Two times you worked out this week. Good!''
Welcome to a rapidly growing phenomenon in the workplace: constant health surveillance.
A digital fitness tracker strapped to Zubko's wrist sends a tally of his daily movements, via the company's UnitedHealth Group insurance account, to an app on his boss's phone. While some employees might find this real-time feedback intrusive, Zubko, 51, said he is unfazed.
"He's a real motivator,'' Zubko said after getting off the phone with Gono.
Devices worn on employees' bodies are an increasingly valuable source of workforce health intelligence for employers and insurance companies. It is fueling a boom in the use of wrist-borne health and fitness monitors, such as those made by Fitbit, Garmin and Apple.
But the volume of highly sensitive health data scooped up from individual employees is exploding, too, raising privacy concerns and adding a new dimension to the relationship between workers and their employers. Often the information is not covered by federal rules that protect health records from disclosure. When it's combined with data such as credit scores, employees are giving up more insights about themselves than they realize.
The ever-more-sophisticated devices are measuring not just steps and distance walked but also the hours a worker spends in a sedentary state, 24/7 heart rate, and sleep duration and quality.
The goal is to help people get fit and save on health-care costs, although evidence is mixed at best about whether the approach works. An employee who barely budges from their desk could be next in line for a medical intervention. That could come from a call center run by Fitbit or a notification from Aetna, which recently announced a new health-monitoring program using Apple watches.
Or, at a small employer such as Regal Plastics, it could come straight from the boss you have known for almost 25 years.
Gono said he had been using Zubko's steps data to push the employee,who handles accounting and purchasingat the Austin office, even before his health crisis in December.
"He just wasn't doing anything'' when it came to exercise, Gono said. "You could tell because he would get less than 2,000 steps every day. He was one of the ones that I personally always challenged.''
Now, since his heart attack, "everybody's pushing this guy,'' Gono added. "We do that with everybody, especially the ones who don't seem to be exercising.''
In general, employees in such programs voluntarily sign up for digital health monitoring. They are lured by cash, reduced premiums, or reimbursements for co-payments and deductibles, which have skyrocketed for many people with insurance. The devices are handed out free or discounted.
Employers and insurance companies are hungry for the resulting explosion of information about workers. Around 20 percent of large firms (200-plus employees) that offer health benefits collected data last year from their employees' wearable devices, up from 14 percent in 2017, according to an annual survey conducted by the Kaiser Family Foundation.
Annual sales of wearable devices for use in company wellness programs will grow to 18 million in 2023 in the United States, according to tech consulting firm ABI Research.
Fitbit is moving aggressively to sign up companies. It added a call service that will contact individual workers - via text messages and phone calls - whose data shows they are falling short of their fitness goals. It is part of a concerted effort to improve the health of entire workforces.
"Sustained behavior change is really the focus,'' said Adam Pellegrini, senior vice president of Fitbit Health Solutions. "Through the system, we can actually see who is not hitting their goals, who is not adhering to that action plan.''
But privacy and workforce specialists warn the data could be abused to favor the healthiest employees while punishing or stigmatizing those who are less healthy, or who show signs of unhealthy behavior such as heavy drinking or drug use.
"The more that employers know about their employees' lives, especially outside the workplace, off-duty hours, the more potential control or effects they have on their lives in the first place,'' said Lee Tien, a senior staff attorney at the Electronic Frontier Foundation, a nonprofit organization that advocates for consumer privacy on the Internet.
"It's quite possible,'' he said, "there will be effects on whether you are retained, promoted, demoted - who is first to be laid off.''
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The vibe at Regal Plastics seems more paternalistic than punitive.
The privately held family firm, headquartered among Irving's office parks and warehouses near the Dallas-Fort Worth International Airport, has 100 employees at several locations around Texas. The company builds desks, outdoor canopies, display cases, stage sets, pet carriers, bulletproof barriers and just about anything else a business or contractor might need.
It's led by Wayne Gono, and his wife, Patsy, whose father founded the business in 1970. Patsy is the company's president. Wayne has taken the title of visionary/chief networking officerand has passed the title of chief executive to the couple's son, Chad, 36, the third generation to take the reins. The company never gave any thought to the fitness of its employees, Wayne Gono said, until a few years ago, when it offered workers a chance to join a UnitedHealth program that distributed basic Trio wrist devices that measure steps.
Enrollees in the program, called UnitedHealthcare Motion, get up to $1,000 a year if they hit certain goals, such as 10,000 steps in a day, 3,000 of those steps within 30 minutes, and 500 steps at intervals throughout the day. The money reimburses health-plan enrollees for prescription co-pays and other payments under their deductibles.
Gono said he has not seen evidence that the program is saving the business money on premiums. But he says it stands to reason that healthier employees will be better for the bottom line - eventually. Regal Plastics employees who wear the devices (many don't, especially younger people who don't have many medical expenses) said they like them.
Gono's UnitedHealth app reveals a list of the top performers. Ronald "Hot Rod'' Wilborn, 47, has an advantage over many of his colleagues and consistently ranks near the top. His job, using precision machines to turn sheet plastic into useful materials, requires him to take multiple trips from the shop to the warehouse. On a recent day, one round trip clocked at 386 steps. He frequently amasses more than 20,000 steps a day. He gets a small check every quarter from UnitedHealth.
"The more I walk, the more I get,'' Wilborn said.
Another employee whom Gono said he personally challenged to lose weight, Eddie Watson, 46, works in the Irving office as a sales representative. He has lost 40 pounds but has hit a plateau and is looking for ways to lose20 more. He has a 6-year-old daughter and takes her to the park near his house to accumulate steps, he said.
During an interview in the Regal break room, Watson munched from a plate of guacamole and greens. Exercise surveillance is part of a broader culture shift at Regal aimed at employee well-being, including the introduction of standing desks, music during working hours, and graphics at work stations that show each person's working style and preferences.
As part of the changing culture, Regal's leaders encouraged employees to "clean up your life, too,'' Watson said. "That kind of planted the seeds.''
Now, Watson said, he examines every aspect of his diet through a prism of personal health. He used as an example: "I can't drink this soda, because there's no place for it in my body." Without encouragement from his employer, he added, none of this would have happened.
One of the few millennials with a step-tracker on his wrist at Regal was Travis Lee, a thin, 29-year-old purchasing agent. He has few medical expenses, so he doesn't even earn money from UnitedHealth for hitting step goals. But on Black Friday last year, he upgraded to a Fitbit Charge 2 because he likes monitoring his steps, sleep and heart rate. He synced it to his UnitedHealth account so he still shows up on Gono's app.
He doesn't worry too much about where his data goes or how it is used. "It's part of the generation. We're used to it,'' Lee said. "We kind of know we're giving something up to use it.''
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Once health and fitness data leaves an employee's wrist, it enters a digital realm that critics say is loosely regulated.
The information streams to an app on the worker's phone, and from there to several possible places: the manufacturer of the device, the health insurance company, the employer or a wellness-plan administrator - or all of them.
Because the wearer of the device is voluntarily giving up data, companies enjoy greater legal leeway in how it is used.
The Blue Cross Blue Shield Association provides one example. The association, which represents Blue Cross health plans across the country, offers a Blue365 wellness monitoring program, which includes member discountsto buy Fitbit devices. When they sign up for the Fitbit app, members can choose to have their information disclosed from Fitbit to their Blue Cross plan and their employers.
"Fitbit is committed to protecting consumer privacy and putting users in control of their personal data,'' the company said in response to questions from The Washington Post. "Fitbit believes that corporate wellness programs should always be inclusive, voluntary and should protect the privacy of the people they are aimed to serve.''
Aetna, which is part of CVS Health, announced last month a new wellness program featuring Apple watches. The company said it is up to users to decide what data they want to share.
UnitedHealth said employers typically have access to "de-identified'' employee data. But there are exceptions. "In some instances, employers may receive certain additional information for plan administrative purposes,'' UnitedHealth said. (At Regal Plastics, Gono's app shows employees identified by unique handles). Privacy and data specialists say the sharing of potentially sensitive health and fitness data is becoming widespread.
Google, Amazon and Apple are rapidly expanding their ability to conduct health analyses based on data shared with them, said Sanket Shah, a senior director at Blue Health Intelligence, which provides workforce health analytics for employers in Blue Cross Blue Shield insurance networks.
"They're basically taking all these troves of data and starting to provide a holistic view of population health and individual health,'' Shah said. "It's handled with care. The data is very sensitive, and if it falls into the wrong hands, it could be devastating.''
Many consumers are under the mistaken belief that all health data they share is required by law to be kept private under a federal law called HIPAA, the Health Insurance Portability and Accountability Act. The law prohibits doctors, hospitals and insurance companies from disclosing personal health information.
But if an employee voluntarily gives health data to an employer or a company such as Fitbit or Apple - entities that are not covered by HIPPA's rules- those restrictions on disclosure do not apply, said Joe Jerome, a policy lawyer at the Center for Democracy & Technology, a nonprofit in Washington. The center is urging federal policymakers to tighten up the rules.
"There's gaps everywhere,'' Jerome said.
Real-time information from wearable devices is crunched together with information about past doctors visits and hospitalizations to get a health snapshot of employees. Sleep monitoring has especially profound implications. Poor sleep can be a key indicator of depression, substance abuse or other mental disturbances. Overweight insomniacs, as measured in this new world, for example, will stand out faster as potentially costly health insurance risks.
Some companies also add information from outside the health system - social predictors of health such as credit scores and whether someone lives alone - to come up with individual risk forecasts.
"The Fitbit or Apple Watch applications . . . may yield clues to things about you that you are not even aware of, or not ready for other people to know,'' said Electronic Frontier's Tien. "Individuals and consumers who are buying these devices don't understand that is a potential consequence.''
YUMA, Ariz. - Staff Sgt. Chris Cazares is panting to catch his breath after slicing down a salt cedar on the banks of the Colorado River with one of those orange-handled saws commonly used in school shop class.
A supervisor at a nursing home, the longtime soldier in the Army National Guard was previously deployed twice to Iraq, where he specialized in neutralizing chemical attacks. Now he is deployed to his hometown on Arizona's border with Mexico. Here, he is neutralizing trees.
Cazares is one of roughly 600 guardsmen serving on the border in Arizona since President Donald Trump dispatched the National Guard last April in support of Customs and Border Protection. Numbering about 2,200 as of early this month, the guardsmen Trump supplied from across the nation answer to the governor of the state in which they are deployed. The active-duty troops the president sent to the border last fall now number about 4,350; they report to U.S. Northern Command.
Whether Cazares and his fellow guardsmen are needed here on the border has become the subject of a renewed debate that has cleaved along party lines. It has again put the U.S. border with Mexico at the center of national political rancor that is poised to escalate after Trump declared a national emergency Friday, bucking Congress to secure more funding for a wall.
In recent days, the newly inaugurated governors of California and New Mexico, both Democrats, ordered the withdrawal of most guardsmen from the border in their states, suggesting Trump had deployed the Guard not because CBP is facing a crisis but rather because the president wants to sow fear and appear tough on illegal immigration by showing off uniformed officers in the field.
California Gov. Gavin Newsom called the deployment a "theater of the absurd" upon withdrawing the bulk of the forces from the border in his state and redeploying them to fight fires and target drugs. New Mexico Gov. Michelle Lujan Grisham, who retained a handful of guardsmen on the border, said her state would no longer abide "the president's charade of border fearmongering by misusing our diligent National Guard troops."
The Republican governors of Arizona and Texas, meanwhile, have kept the full National Guard border deployments in their states. Supporters of the deployment say the back-end assistance from the Guard frees up Border Patrol agents to deal with threats from drug smugglers and human traffickers. Presidents George W. Bush and Barack Obama, they point out, both deployed the National Guard to the border during their presidencies.
The American military cannot conduct domestic law enforcement activities owing to an 1878 federal law called the Posse Comitatus Act. As a result, the uniformed personnel are helping in the background rather than dealing directly with migrants crossing the border.
In Yuma, about 100 guardsmen are performing ancillary tasks for CBP - clearing brush, fixing machinery, stocking foodstuffs and monitoring surveillance cameras at the sector headquarters. The idea is to free up border agents previously assigned to those duties so that they can instead apprehend and process migrants.
"It's kind of a godsend," said Vincent Dulesky, special operations supervisor for public affairs at the Border Patrol's Yuma sector. "As we were getting strained out, you have the National Guard."
The 126-mile stretch of Arizona and California border that comprises the Yuma sector is a mélange of worlds - tribal areas, military installations, government parks, majestic sand dunes and vast stretches of agricultural land, much of it harvested by Mexican seasonal laborers who traverse the border with work permits. Sometimes described as the sunniest place in the United States, Yuma grows much of America's lettuce. In a local souvenir shop, one Yuma T-shirt reads: "If you've had a salad in the winter, you're welcome."
Overall, the number of people apprehended for crossing the border illegally has decreased dramatically from a multi-decade high nearly two decades ago. In the Yuma sector there were 26,244 apprehensions of migrants crossing illegally in the 2018 fiscal year, down from 108,747 in 2000. Across the entire border with Mexico, apprehensions decreased to 396,579 from 1.68 million over the same time period.
Although the number of apprehensions in Yuma are down from 20 years ago, they have more than quadrupled since 2014 amid an influx of families and children, primarily from Honduras and Guatemala, fleeing poverty and violence. The number of border agents assigned to the sector, meanwhile, is roughly the same now as it was in 2014.
More than three-quarters of the people apprehended in Yuma last year crossed as unaccompanied minors or members of families including children. They tend to surrender to Border Patrol immediately after crossing into U.S. territory in what the agents call "give ups" - and many file asylum claims. Border Patrol is supposed to hold them for a maximum of 72 hours. After that, Immigration and Customs Enforcement can keep minors in immigration detention for no longer than 20 days. If a family hasn't received a hearing by then, authorities must transfer the children to a licensed child-care facility or release them with a parent, who often receives a tracking bracelet and a court date.
The Trump administration says these standards create a loophole that is incentivizing migrants to cross the border with children and remain in the United States illegally after their release.
The administration initially tried to stem the influx of Central American families by separating children from parents who entered unlawfully, prompting a national outcry. Now the administration has moved to terminate the 20-day rule and expand ICE's family detention facilities.
In Yuma, Border Patrol agents say the changing character of the migration has strained their force. Whereas years ago they tracked mostly Mexican border crossers looking to evade detection, now they say children and families from Central America are showing up in large groups, many requiring medical care after a perilous journey through the Sonoran Desert.
Last month, a group of 376 migrants from Central America crossed into the sector by burrowing under one of the walls erected there during the Bush administration. Nearly half of them were children.
"Every day that we get over 100 in a group is a strain," Border Patrol agent Justin Kallinger said.
When the sector was apprehending adult Mexican border crossers, agents would detain them for an average of about eight hours and often send them back across the border, Kallinger said. Now, he said, the average time in sector custody is about the 72-hour maximum, because Central American migrants require a flight to get home and often are making asylum claims. Agents must provide transport, hospital escorts and food in the interim, duties now claiming far more of their time.
For relief, they are relying on the National Guard.
"Guard. Boom. Here we are," says Tech. Sgt. Dan Broughton, a 36-year-old member of the West Virginia Air National Guard, who after four combat tours in Iraq and Afghanistan is monitoring cameras and sensors in the sector's surveillance room.
Now staffed by about half guardsmen and half civilian employees, the room no longer has border agents behind the monitors because they were moved to front-line law enforcement roles.
In a supply room across the parking lot, guardsmen surrounded by diapers, bottles, baby formula, emergency blankets, cheese crackers and Cup Noodles have come up with a trolley-cart system to save border agents time while distributing goods to detained migrants.
Closer to the border, Cazares is overseeing about 17 guardsmen on the "vegetation team," which is clearing brush along a part of the Colorado River that forms the border with Mexico for seven miles.
The goal, he says, is to give migrants coming across the river fewer places to hide and ensure that CBP cameras affixed to nearby towers can scan the area without obstruction. Though most of the sector's crossers are looking to surrender, the agents say some still seek to evade detection.
Before the guardsmen arrived, about six border agents who have now been moved to primary law enforcement duties took responsibility for taming the brush, Dulesky said.
Whether the Guard is the most cost-effective way to relieve Border Patrol sectors is a question of cost and the definition of need. The deployment is projected to cost the Defense Department about $550 million by the end of September, raising questions about whether the same funds could have gone directly to CBP for additional agents, technology and resources, offering a more permanent fix.
Guard missions tend to cost the Pentagon more than active-duty ones, because guardsmen receive additional pay and benefits when deployed. Most of the guardsmen deployed to Yuma are staying in local hotels; active-duty forces operating in the United States tend to stay on bases.
On Friday, Trump said a bill Congress passed to fund border security this week provided "so much money, we don't know what to do with it," just not enough for the wall. The additional funding raised questions about using relatively expensive uniformed personnel to carry out duties such as clearing trees.
On the river outside Yuma, those are faraway Washington concerns.
On the American side, Mexican seasonal workers are harvesting broccoli for American diners. On the Mexican side, the clouds are hovering over Los Algodones, a town nicknamed "Molar City" for its bargain Mexican dentists who fix American teeth.
Cazares is busy getting "down and dirty" with his team, which has cleared more than 165,000 square feet of brush since mid November. He is upbeat, unfazed by a job that can involve laboring under the brutal desert sun.
"Everything has to be cleared out," the 42-year-old says with a sweep of the hand across the horizon.
The alarm on a mobile phone blares, interrupting Cazares as he extols Yuma's bean-and-cheese burritos. The chorus of machetes and axes tires into silence, and guardsmen catch their breath. Cazares spins around, "Break!"