Focus groups showed lack of support for penalty-based systems

When West Virginia experimented with penalty-based systems that withdrew some Medicaid benefits if beneficiaries didn't comply with certain behaviors, focus groups were done to gauge the public's reaction to this.

"We found that it was very unpopular," reports Joan Alker, co-executive director at the Georgetown Center for Children and Families and a research associate professor at Georgetown University's Health Policy Institute. "Obviously, a focus group is not a poll, but people really didn't like it." This was true even for conservatives, who saw it as an unwanted government intrusion, adds Ms. Alker.

Medicaid clients were required to sign a contract stating that they'd adhere to certain behaviors, and if they failed to, their benefits would be limited, Ms. Alker explains. Participants in the state's Basic program who failed to adhere to the requirements were limited to four prescriptions a month, for example.

"It was very troubling to have an arbitrary limit on that, especially for children's coverage. What are you trying to achieve by cutting children off prescription drugs that they might need?" asks Ms. Alker, who authored a report on West Virginia Medicaid's program.1

In 2008, Ms. Alker evaluated Florida's efforts to incentivize healthy behaviors with its Enhanced Benefits Rewards Program. Credits of up to $125 a year were given to Medicaid clients for various activities, ranging from keeping doctor's appointments to participating in a weight management program.2 The program has been done as part of a waiver for the past five years in several Florida counties, explains Alker.

"We found that the vast majority of credits were awarded for simple things, like keeping an appointment. Very few credits were awarded for more complex activities," she says.

During focus groups with Florida's Medicaid beneficiaries, Alker learned that very few of them were aware of the program. "There wasn't any evidence that the incentives changed behaviors, but that was in part because it wasn't a very targeted program," she says. "It was popular with beneficiaries when they learned about it."

To effectively encourage healthy behaviors, says Ms. Alker, states need to be very clear on what behavior they are trying to change and in whom. "Remember that most Medicaid beneficiaries are children. So there is a question of whether you are trying to change children's behavior, or their parents' behavior," she says. "Unfortunately, a lot of times these discussions aren't concrete enough."

Penalties for obesity and smoking in Medicaid are not generally supported by the public, says Michael Perry, a partner at Lake Research Partners, a Washington, DC-based national public opinion and political strategy research firm, in part because people fear they could be imposed in private health plans next.

Rather, he says, the public supports more access to smoking cessation and nutritionists. "They also are more likely to support incentive programs and lower costs for those who improve their health," says Mr. Perry.

Polling on this topic is unreliable, adds Mr. Perry. "It is possible to frame this issue in such a way that you get a high number of people saying, 'Yes, let's impose a fee on people who receive Medicaid and who smoke or are obese,'" he says. "The knee-jerk response is to blame people who have Medicaid and who are obese and who smoke."

However, more thoughtful questions on this topic inevitably show people are uneasy with penalties on people who struggle with obesity or smoking, says Mr. Perry. They worry that such penalties are unfair to people who are trying to improve their health but cannot for genetic or other reasons, he explains, and that penalties could be imposed on them next.

"They do not like government interference in the lives of individuals, telling them what to do," says Mr. Perry.


1. Alker J. West Virginia's Medicaid redesign: What is the impact on children? August 2008. Georgetown University Health Policy Institute, Washington, DC.

2. Alker J, Hoadley J. The enhanced benefits rewards program: Is it changing the way Medicaid beneficiaries approach their health? Briefing #6, July 2008. Georgetown University Health Policy Institute, Washington, DC.