Paying People to Make Healthy Choices

Abstract

Paying people to make healthy choices is a promising response to a genuine social problem. Many people engage in behaviours that are not only destructive of their health but also impose significant financial burdens on themselves and their societies. Paying people to make healthy choices can be more effective than the mere provision of information, while also being more efficient and ethical than outright prohibitions of unhealthy behaviour. An enormous range of empirical research confirms this basic insight. However, when it comes to the success of any given programme, the devil is in the details. Health incentive programmes need to be carefully designed and evaluated to ensure that they are indeed effective, efficient and ethical. Moreover, special attention must be paid to concerns about equity, unjustified paternalism, the effects on character and perverse incentives that can generate unintended consequences.

Key Concepts

  • Unhealthy behaviours impose large costs on healthcare systems, and many people later regret their unhealthy choices.
  • Policymakers would like to encourage healthier behaviour, but the challenge is to do this in ways that are effective, efficient and ethical.
  • Paternalists argue that we should encourage people to make healthy choices for their own good, while utilitarians argue that we should encourage people to make healthy choices because of the larger benefits to society.
  • Both paternalists and utilitarians have argued that extremely unhealthy choices, such the recreational use of narcotic drugs, should be prohibited. However, although effective, prohibitions of unhealthy behaviour are often inefficient and raise ethical challenges.
  • Concern for individual rights and autonomy has led many to criticise prohibitions on unhealthy behaviour, arguing that it would be better to simply inform people about the costs and harms of unhealthy choices. Unfortunately, information campaigns have had limited success in changing unhealthy behaviour.
  • Paying people to make healthy choices promises to be more ethical and efficient than prohibitions and more effective than the provision of information.
  • Paying people to make healthy choices can be more ethical because it still allows people to make a choice; it can be more efficient because rewards and penalties can be adjusted to reflect the social costs of unhealthy behaviours; and it can be more effective because it provides immediate incentives to make a healthy choice.
  • Health incentive programmes have been successful in many different circumstances. However, programmes need to be carefully designed and evaluated to ensure that they are indeed effective, efficient and ethical.
  • There are circumstances in which paying people to make healthy choices may not be the best approach. Particular attention must be paid to concerns regarding equity, unjustified paternalism, the effects on character and the creation of incentives that lead to unintended consequences.

Keywords: health incentives; healthcare costs; paternalism; public health; ethics of incentives; healthy choices

References

Blocker, J. S. (2006). Did prohibition really work? Alcohol prohibition as a public health innovation. American Journal of Public Health, 96(2), 233–243. http://doi.org/10.2105/AJPH.2005.065409

Centers for Disease Control and Prevention (CDC) (2009) The Power of Prevention: Chronic Disease, the Public Health Challenge of the 21st Century. http://www.cdc.gov/chronicdisease/pdf/2009‐power‐of‐prevention.pdf

Centers for Disease Control and Prevention (CDC) (2016) Chronic Disease Overview. http://www.cdc.gov/chronicdisease/overview/index.htm

Durkin S, Brennan E and Wakefield M (2012) Mass media campaigns to promote smoking cessation among adults: an integrative review. Tobacco Control 21 (2): 127–138.

Grant RW (2011) Strings Attached: Untangling the Ethics of Incentives. Princeton: Princeton University Press.

Halpern SD, French B, Small DS, et al (2015) Randomized trial of four financial‐incentive programs for smoking cessation. New England Journal of Medicine 372 (22): 2108–2117.

Higgins ST, Budney AJ, Bickel WK, et al. (1994) Incentives improve outcome in outpatient behavioral treatment of cocaine dependence. Archives of General Psychiatry 51: 568–576.

Higgins ST, Silverman K, Sigmon SC and Naito NA (2012) Incentives and health: an introduction. Preventive Medicine 55: S2.

Jeffery RW. (2012) Financial incentives and weight control. Preventive Medicine ;55S:S61–S67.

Kiszko KM, Martinez OD, Abrams C and Elbel B (2014) The influence of calorie labeling on food orders and consumption: a review of the literature. Journal of Community Health 39 (6): 1248–1269.

Mansfield H (2008) On Religion and Rational Control. Bradley Lecture at AEI, November 3, 2008.

Miron, J. A., and Waldock, K. (2010). The Budgetary Impact of Ending Drug Prohibition. Washington, DC: Cato Institute. http://object.cato.org/sites/cato.org/files/pubs/pdf/DrugProhibitionWP.pdf

Ranganathan M and Lagarde M (2012) Promoting healthy behaviours and improving health outcomes in low and middle income countries: a review of the impact of conditional cash transfer programmes. Preventive Medicine 55: S95–S105.

Sigmon SC and Patrick ME (2012) The use of financial incentives in promoting smoking cessation. Preventive Medicine S55: S24–S32.

Stitzer ML, Bigelow GE and Liebson I (1980) Reducing drug use among methadone maintenance clients: contingent reinforcement of morphine‐free urines. Addictive Behaviors 5: 333–340.

Sunstein CR and Thaler RH (2008) Nudge: Improving Decisions about Health, Wealth, and Happiness. New Haven, CT: Yale University Press.

Volpp KG, Troxel AB, Pauly MV, et al. (2009) A randomized, controlled trial of financial incentives for smoking cessation. New England Journal of Medicine 360 (7): 699–709.

Woolf, S. H., & Aron, L. (Eds.). (2013). US Health in International Perspective: Shorter Lives, Poorer Health. National Academies Press. http://iom.nationalacademies.org/Reports/2013/US‐Health‐in‐International‐Perspective‐Shorter‐Lives‐Poorer‐Health.aspx

Wu S and Green A (2000) Projection of Chronic Illness Prevalence and Cost Inflation. RAND Corporation.

Further Reading

Becker GS (2013) The Economic Approach to Human Behavior. Chicago, IL: University of Chicago Press.

Gounder C (2013) The future of getting paid to be healthy. The Atlantic June 3, 2013. http://www.theatlantic.com/health/archive/2013/06/the‐future‐of‐getting‐paid‐to‐be‐healthy/276461/

EL Giles, S Robalino, FF Sniehotta, J Adams, E. McColl, Acceptability of financial incentives for encouraging uptake of healthy behaviours: a critical review using systematic methods, Preventive Medicine, 73, 2015, 145–158, ISSN 0091‐7435, 10.1016/j.ypmed.2014.12.029.

Grant RW (2011) Strings Attached: Untangling the Ethics of Incentives. Princeton: Princeton University Press.

Haff N, Patel MS, Lim R, et al. (2015) The role of behavioral economic incentive design and demographic characteristics in financial incentive‐based approaches to changing health behaviors: a meta‐analysis. American Journal of Health Promotion 29 (5): 314–323.

Hall B (2008) Health incentives: the science and art of motivating healthy behaviors. Benefits Quarterly 24 (2): 12–22.

Lite J (2011) Money over matter: can cash incentives keep people healthy? Scientific American, March 21, 2011. https://www.scientificamerican.com/article/can‐cash‐incentives‐keep‐people‐healthy/

E. Mantzari, F. Vogt, I. Shemilt, Y. Wei, JP Higgins, TM Marteau, Personal financial incentives for changing habitual health‐related behaviors: a systematic review and meta‐analysis, Preventive Medicine, 75, 2015, 75–85, ISSN 0091‐7435, 10.1016/j.ypmed.2015.03.001.

Sunstein CR and Thaler RH (2008) Nudge: Improving Decisions about Health, Wealth, and Happiness. New Haven, CT: Yale University Press.

Wieczner J (2013) Your company wants to make you healthy. Wall Street Journal, April 8, 2013. http://www.wsj.com/articles/SB10001424127887323393304578360252284151378

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How to Cite close
English, William(Mar 2017) Paying People to Make Healthy Choices. In: eLS. John Wiley & Sons Ltd, Chichester. http://www.els.net [doi: 10.1002/9780470015902.a0026500]