Do incentives, penalties work? Not much evidence to date

The idea of using a fee and incentive structure to motivate consumer behavior change, as Arizona is attempting to do with a proposed $50 fee on smokers and obese Medicaid clients, is certainly appealing, says Donna Friedsam, MPH, health policy programs director at the University of Wisconsin Population Health Institute in Madison.

"On the face of it, $50 does not seem a lot, as a marginal added fee for enrollment in a health coverage program," says Ms. Friedsam. However, it's unlikely that the $50 fee would achieve the health-related goals of the program, she says.

"Arizona may be attracting attention for its specific approach, but it is not the first state to try inserting incentives into Medicaid to address smoking, obesity, or other health behaviors of its members," she says.

West Virginia was perhaps the first state to experiment with penalty-based incentives systems that withdrew Medicaid benefits when patients did not comply with state behavioral requirements, notes Ms. Friedsam.

The state's Medicaid program made two levels of health care benefits available, contingent upon specified behaviors and compliance with a member contract, says Ms. Friedsam. Wisconsin, Florida, Idaho, and other states have pursued incentive-based programs, she adds, rewarding Medicaid members for achieving specific goals or meeting certain behaviors, particularly around preventive care.

"These programs have not yet demonstrated the utility of such incentives in promoting behavior change among the Medicaid members," says Ms. Friedsam.

A missed opportunity

While existing research suggests that small economic incentives may motivate short-term efforts, says Ms. Friedsam, these are particularly weak in achieving sustained weight loss or smoking cessation.

Penalties could actually deter current smokers from enrolling in health coverage and attaining the health care intervention that they need to quit smoking, according to Ms. Friedsam. "Research clearly demonstrates that people are most likely to break their tobacco dependence when provided with effective medications, as well as counseling and behavioral treatment," she says.

Obesity poses even greater challenges, says Ms. Friedsam, and existing health care interventions have demonstrated only modest success.

"The question here is whether it is reasonable to expect adults who are potential Medicaid beneficiaries to achieve individual weight loss, when these low-income persons face the greatest barriers to healthy food choices and active lifestyles," she says.

Medicaid clients often lack access to safe outdoor activity spaces, recreational facilities, affordable fresh produce, and the time or knowledge to achieve lifestyle change, she explains.

Arizona's approach is most likely to simply deter enrollment by those with the lowest income who do not have a current health condition other than smoking or obesity, says Ms. Friedsam. However, she adds, these individuals will continue to incur expenses on the health care system on an episodic and uncompensated basis through hospital emergency departments and other safety net venues.

"The Medicaid program will have missed an opportunity to enroll them, and provide the preventive services that might have broken their tobacco dependence or helped avert or manage pre-diabetes, and thus avert later health care costs that will inevitably be borne systemwide," says Ms. Friedsam.

Contact Ms. Friedsam at (608) 263.4881 or