Should We Bribe People to Be Healthy?

by JHI Staff on March 26, 2013

Most experts concerned about obesity would argue that getting rid of humongous servings of heavily sugared beverages in restaurants and food retailers is a no-brainer, merely a tiny first step toward a sharper series of changes we need to make in our obesogenic environment. And yet the uproar over New York City Mayor Michael Bloomberg’s efforts to ban these absurd portions and unhealthy products makes it clear that when it comes to regulating food, much of the public isn’t ready to have its food options limited by government fiat. (Not to mention that most governments aren’t ready to try. New York City is nearly alone in even this small effort—check out Mississippi’s response—and even then the New York ban was blocked by a judge.)

Medicine has come to recognize that one of the most important paths to better health is getting people to adopt healthier habits, including eating right, exercising and not smoking. Regulation can be one way of promoting these changes, but tends not to fly with the American public. What other tools are available to governments to help people adopt new behaviors? Public education is the classic approach, and is well worth doing, but generally has a very limited effect. Taxing products that promote unhealthy or otherwise undesired behavior is another option, but is nearly as unpopular as regulation, isn’t always effective unless the tax is nearly draconian, and frequently ends up being a burden on the poor.

But what about incentives? Rewarding people for doing right thing is a kinder, gentler approach that fewer are likely to object to—though there is always the argument than any form of government intervention causes problems, especially in terms of spending. Studies have long suggested that most people respond better to rewards than punishments, especially when comes to changing habits. We overeat because it’s immediately and intensely rewarding. It’s much easier to plop down in front of the TV instead of getting out for a walk or some exercise. Maybe some cold, hard cash, to name one thing, would be enough of a reward to counter that.

The U.S. government, at least, doesn’t use incentives all that often to nudge people for changing their behavior. Tax credits for buying alternative-energy vehicles is one example, but it’s hard to find many more. There are now many calls within health care for incentives, both for patients in terms of lower insurance premium and for clinicians and hospitals in terms of higher reimbursement, and in fact the Affordable Care Act (alias “Obamacare”) will be trying to push the system in that direction. It could be a decade or more before we know for sure whether that can be done, and whether it works.

As it turns out, we’ll soon have a faster way to witness the results of a strong government-run incentive program aimed at health. We just have to look to the United Arab Emirates to see it. There, the government of Abu Dhabi has recently announced a “pay-for-health” scheme that will financially and otherwise reward citizens who achieve various health and wellness benchmarks, especially those related to diabetes. That may be the world’s first case of a government offering a cash reward for good health. In theory, people will feel it’s more worth their while to engage in healthier behavior, and if they do, the new behavior ought to pay off health-wise in measurable ways, which would serve as a nice validation of the incentive approach.

If the scheme works, it would likely slash health care costs—as studies and analysis have consistently indicated—which means this sort of pay-for-health scheme might not only improve health through behavior change, it might actually save the government money. Call it a bribe if you want, but by any name this sort of incentive could be a good idea.

I hope it does work, and if it does I hope governments at all levels all over the world, including in the U.S., take careful note. Even if a direct pay-for-health scheme isn’t feasible here in the U.S. (not that I think it isn’t), there certainly would be lots of ways of finding new, significant incentives to get people to do their share.

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Brian Pinto March 27, 2013 at 12:22 pm

Incentives for healthy behavior are long overdue in the US. You can see some examples of insurers waiving prescription co-pays for medications or reduction in premiums if the member demonstrated certain healthy behavior. The moral hazard accociated with "free" healthcare also has been demonstrated. Since some degree of financial risk sharing is necessary for almost every insurance model, incenting healthy behavior to reduce that financial burden to the patient seems logical. As you mention, positive incentives work whether your dealing with a 4yo or 40 yo, the trick is finding the right ones to achieve the desired behavior.

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EC March 26, 2013 at 11:58 pm

Well instead of raising tax on unhealthy products (which would never happen with big corporations lobbying the government), how about we reduce the tax and ease the regulations on organic producers, small local farmers so that their products are more affordable compared to the unhealthy option. I think that would work better for most poor families. But what does the government do instead? They quietly pass the bill that protects Monsanto and GMO products from lawsuits...

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lubna March 26, 2013 at 11:47 am

I believe that food corporations should work more to incorporate healthier food items in food products. We need to pass more policies and legislation to make sure that the process from plate to food is morally ethical. For example: A lot of food products have too much of one ingredient in it, corporate farming and its ability to grow at such high rates (animals & crops), among other things contibute to the obesity pandemic. How are u going to tell lower income families that live on the streets that their will be a reduction in insurance rates when they cannot even afford insurance and are not employed. Using medical bench markers is unfair as well because many lower income families do not have the educations or tools to become healthy.

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