Can we pay medicaid users to lose weight, quit smoking?

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Carrots are much more popular than sticks right now. Wiggle a carrot in front of a hungry rabbits face, conventional wisdom says, and he'll come running. Perhaps it's a better way to get a rabbit where you want him than to wallop him with a stick.

Do humans work the same way? A new federal grant program gives states $100 million to incentivize their medicaid recipients to make healthier choices, like losing weight or quitting smoking. But can it be done? Are human beings as gullible as hungry rabbits? Or are we about to shell out a load of cash for some useless carrots?

The idea is this: Medicaid is too expensive. It costs us way too much. So if we can figure out a way to prevent people from getting sick, we can spend a lot less on health care.

A few states have tried it already. Idaho has tried giving vouchers for gym memberships, smoking cessation programs, weight management programs and nutritional counseling in exchange for medicaid patients meeting with a doctor about their health issues. West Virginia offers an enhanced coverage program for medicaid recipients who choose healthy behavior.

But neither of these programs have shown measurable results.

Private employers and health care companies have had some success with giving incentives to lose weight. A study in the Journal of American Medicine shows that paying people to lose weight can work, at least in the short term.

These incentive programs are all the rage right now, not just showing up in health care, but in poverty policy and education. An article in Time magazine last year chronicled the effects of a program that paid children for good grades in four different cities. One discovery it made, one that always sticks in my head when it comes to incentive programs, is that just because people want the carrot doesn't mean they know how to get it:

We tend to assume that kids (and adults) know how to achieve success. If
they don't get there, it's for lack of effort--or talent. Sometimes
that's true. But a lot of the time, people are just flying blind. John
List, an economist at the University of Chicago, has noticed the
disconnect in his own education experiments. He explains the problem to
me this way: "I could ask you to solve a third-order linear partial
differential equation," he says. "A what?" I ask. "A third-order linear
partial differential equation," he says. "I could offer you a million
dollars to solve it. And you can't do it." (He's right. I can't.) For
some kids, doing better on a geometry test is like solving a third-order
linear partial differential equation, no matter the incentive.

I wonder if losing weight or quitting smoking will face similar challenges. People living in poverty may want to lose weight. They may know they need to lose weight to avoid serious health problems. But how to do it? That's tougher.

For many Chicago residents who live in poor neighborhoods, healthier food is hard to find. And even if they can find it, they may not be able to afford the expense of fresh produce, meat and lean dairy, rather than cheaper, processed foods. Then, there's getting exercise. With many of Chicago's poor living in violent neighborhoods, getting outside may not be much of an option, nor would an expensive gym membership, if they can find the time to go.

It's not that losing weight would be impossible. Just that the path to getting there might not be so clear or easy. They might have a tougher time than a person with access to healthy food, a decent income and lots of resources.

Incentives can be great tools. They can motivate us to do things we thought we couldn't. But before we invest a $100 million in incentives, shouldn't we have something more substantial to back it up? And a reason to believe that change is as easy as dangling the right carrot?

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