OPINION: Inherent myopia

April 30--Dr. David Becker is a professor at the University of Alabama-Birmingham School of Public Health who specializes in health care organization and policy. What follows are his responses to my questions via email.

-- Bob Davis

BD: Both of my sources focused on the long-term goal of creating a healthier society that, in turn, lowers the rates of obesity, diabetes, heart disease and so on. They asked: Where are the incentives for Americans to live healthier lives?

DB: The primary incentive to engage in healthy lifestyle behaviors is better individual health today and in the future. The biggest challenge to lifestyle modification -- whether it is exercising, eating right, quitting smoking/drinking/drug use -- is that the costs of behavioral change are incurred in the present while the benefits are realized in the future. To varying degrees, our impatience leads us to overweight the pleasure of today relative to the the health consequences of tomorrow.

So the question arises, how can [we] overcome our inherent myopia? How can we make individuals less present-oriented and more focused on their long-run interests?

Although the majority of the benefits (harms) of our individual lifestyle choices accrue to us as individuals, there are numerous ways in which society benefits from improvements in population health. The external effects of good health include lower health-care spending (insurance premiums, taxes to fund public coverage), economic growth (workforce productivity) and public safety (from improvements in mental health and economic well-being).

These "externalities" provide the justification for public policy that encourages healthy lifestyle behaviors. On the incentive front, the Affordable Care Act has given employers much greater latitude to use financial incentives to encourage workplace wellness. Although the efficacy of financial incentives in improving population health is not well established, these programs represent a paradigm shift in employer-based coverage where workers will be rewarded/penalized based on health behaviors and/or health status. The federal government has also funded demonstration grants to state Medicaid agencies to experiment with incentive-based programs for health promotion.

At the same time, new insurance market regulations under the ACA reduce the economic incentives to maintaining good health. Insurance companies are no longer able to charge different premiums based on health status, which benefits the sick at the expense of the healthy. If health status were entirely a function of modifiable health behaviors, this would clearly disincentive healthy lifestyles. However, the justification for these new insurance market regulations is rooted in the fact that health status is also determined by factors outside our control.

BD: The doctor told me that more times than not, patients reject his advice of making healthy changes. Instead, pre-diabetics, for instance, simply say they just want the pill or whatever keeps them from making serious lifestyle changes.

DB: As I wrote above, one of the biggest failings of human beings is that we are impatient, perhaps increasingly so.

Going to the gym five times a week, limiting fast food, cutting down on snacking -- all of that is hard. Taking a statin or anti-hypertensive is not.

There is also an element of risk-aversion at play as some patients (and their physicians) don't want to run the risk of waiting to see if lifestyle modifications will work.

BD: I'd love to hear your input on these matters. Further, is it possible to create a health-care system that builds in the type of incentives that would lower demands on our health-care infrastructure?

DB: It is certainly appealing to envision reforms that would lead individuals to adopt healthy lifestyle behaviors, thereby lowering costs and improving population health. There are several important questions about the efficiency of financial incentives to improve health.

First, will incentives be effective at improving health or do they simply transfer wealth from one set of people to another? The efficiency of incentive payments will depend on the proportion of the population who adopts a healthy behavior in response to incentives relative to the proportion already engaged in the behavior. Second, do the incentives reward/penalize outcomes that are truly modifiable? Some incentives are less contentious (insurance penalties based on smoking status) than others (insurance penalties based on BMI).

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