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Underappreciated provisions in the Affordable Care Act encourage third-party payers — employers, private health insurers, and public Medicaid programs — to take a more active role in reducing health care costs by conditioning the terms of coverage on individuals’ compliance with recommended health behaviors. Champions of this approach, which I call “personal responsibility for wellness,” argue that it could help halt rising health care costs and turn the tide against some of the most pressing public health problems of our time. Employers exhibit enormous enthusiasm for programs that condition financial rewards and penalties (typically in the form of premium discounts or surcharges or differential cost-sharing through deductibles, co-pays, and co-insurance) on individual participation in wellness programs ranging from health screenings to weight loss counseling. At the same time, Medicaid programs in politically conservative states have been experimenting with applying the corporate wellness program model to their Medicaid populations, with mixed results. Critics of these programs are concerned that they may simply shift health care costs from third-party payers to individuals without resulting in better health outcomes. Given that there is often a lapse of decades between behaviors like tobacco use, unhealthy eating, or physical inactivity and the health care costs associated with them, and given that Americans frequently move from one form of health care coverage to another over the course of a lifetime, third-party payers’ interests may not be entirely well aligned with sound prevention policy. Elsewhere, I have argued that personal responsibility reforms reflect cultural biases that exaggerate the extent to which ill health is attributable to the personal failings of unhealthy individuals and that they serve as a political distraction from less punitive measures aimed at making our communities, workplaces, schools, and marketplaces more conducive to healthy living. Here, I assess ongoing agency implementation of the ACA’s personal responsibility for wellness reforms and find cause for hope. I argue that in implementing these provisions, the Department of Health and Human Services appears to be taking an appropriately skeptical stance toward personal responsibility for wellness measures that use rewards and penalties to encourage, but not necessarily facilitate, healthier behavior. I conclude by arguing that recent agency actions are a step in the right direction, but continued vigilance is necessary to ensure that third-party payers do not use wellness reforms to undermine the ACA’s goals with respect to health care access and disease prevention. I also suggest that public health advocates should continue to seek the support of third-party payers in their efforts to transform our workplaces, communities, schools, and marketplaces to make them more conducive to healthy living.

Access to Health Care as an Incentive for Healthy Behavior - An Assessment of the Affordable Care Act's Personal Responsibility for Wellness Reforms