Whether and to what extent people should be held personally responsible for their health has been a subject of debate in the United States for at least three decades.1 In the last few years, however, a new crop of proposals to promote healthy behaviors has been testing both our collective tolerance for such policies and our public health values.
These proposals take two basic forms. One waves carrots; the other wields sticks. Most proposals use some form of incentive to reward individuals for adopting behaviors that protect against disease and promote health. Others, thus far in the minority, take a more punitive tack. In these cases, people who do not adopt the specified behaviors or meet the specified health criteria may forfeit benefits, pay more for them, or even lose their jobs (and so their benefits).
Examples of the carrot approach can be found in both public and private sectors. A number of state legislatures are planning or have implemented policies designed to encourage Medicaid beneficiaries to take up health-promoting behaviors and stop health-harming ones. Florida, for example, offers up to $125 per year in drug store credits as a reward for keeping primary care and annual screening appointments, getting flu shots, participating in smoking cessation and weight loss programs, and so on. Within the private sector, employers are ramping up wellness programs by, for example, offering everything from DVDs to iPods to plane tickets to employees who participate in on-site exercise programs and health screenings.
Examples of the stick approach are also on the upswing, thanks in part to two recent government actions. First, the 2005 Deficit Reduction Act, signed into law in February 2006, gave states new options for reducing Medicaid benefits. West Virginia, one of the first states to act on the law, has scaled back the basic benefits package and offers an “enhanced” package of services to clients who sign (on behalf of themselves and their children) and comply with a “Medicaid Member Agreement” plan. This plan, now being implemented in three counties, requires physicians to monitor and report whether clients undergo screening exams, take prescribed medications, show up for appointments, and so on. Those who fail to do so risk being relegated to the basic package, which lacks some services that many would consider basic.
Second, according to government-issued rules that became effective in July 2007, some forms of penalty-driven wellness programs do not run afoul of the nondiscrimination provisions of the Health Insurance Portability and Accountability Act. Although uncertainty remains about the limits and legality of such programs, business leaders have responded enthusiastically. One well-publicized example is the plan by Clarian Health, a large Indianapolis health system, to charge employees up to thirty dollars per paycheck when they fail to meet benchmarks related to body mass index, cholesterol, blood glucose, and blood pressure. Other employers are taking aim at tobacco use. For example, the company that makes Scotts lawn care products screens potential and current employees for tobacco use and has fired them for it—a practice for which the company has been taken to court in Massachusetts. [End Page 13]
The social goal of promoting healthy behaviors is reasonable given the nature of the U.S. disease burden today. Behavioral patterns make an indisputably significant contribution to the origin and progression of chronic disease, which kills seven out of ten Americans. Daily choices related to diet, exercise, substance use, and risk-taking “represent the single most prominent domain of influence over health prospects in the United States.”2 Yet how to promote behavior change is a complex question. Health behaviors are notoriously difficult to change, even within the context of expertly designed and implemented interventions. This fact may be related to another: health choices and the outcomes to which they contribute tend to be structurally patterned by socioeconomic status, race, and ethnicity. Socially disadvantaged groups are disproportionately exposed to health risks, are more likely to engage in unhealthy behaviors, and experience worse health and shorter lives than those who are better off. Many epidemiologists have noted what David Williams and Chiquita Collins put succinctly more than a decade ago: “A robust inverse association...