The red rag of health incentives

In this guest post, Harald Schmidt from the University of Pennsylvania takes apart the media furore about a proposal  (at least as reported) to cut payments to unhealthy benefit claimants if they didn’t go to the gym – using the insights gained from his previous work on the ethics of incentives in health & social policy.

Pain on a treadmillHealth incentives are of increasing interest to policy makers. Yet, they are highly controversial. For many, they are outright irritating. Unhelpfully ambiguous policy proposals do little to move towards a more nuanced discussion. The recent controversy around a section in a Report by the Local Government Information Unit (LGiU) and Westminster Council is a case in point, and allows several lessons to be learned. 

The full Report section in question reads as follows:

“Linking welfare measures to behaviours that promote public health. Relocalisation of council tax benefit and housing benefit combined with new technologies provide an opportunity for councils to embed financial incentives for behaviours that promote public health. The increasing use of smart cards for access to leisure facilities, for instance, provides councils with a significant amount of data on usage patterns. Where an exercise package is prescribed to a resident, housing and council tax benefit payments could be varied to reward or incentivise residents.”

For many, this passage seemed to have but one aim: to use electronic surveillance technology to coerce poor and often marginalized overweight people into gyms. In a neoliberal triumph of Foucauldian biopower, benefits will be cut if the pounds aren’t shed. The media echo uniformly viewed the proposal critically (Guardian, Independent, BBC, Daily Mail, Daily Telegraph). One commentator opined “[this] is the kindly face of hatred, the result of mixing a loathing for poor people with the wider medically sanctioned disgust of fat in order to do things a bit more cheaply.”

I cannot claim to know anything about the personal intentions of the proposals’ authors. But the text alone seems insufficient to support this view. If we want to appraise the ethics (or absence of such) of the approach, we need to read more closely. Admittedly, this is challenging: the proposal is carelessly imprecise, since it says nothing about the crucial issue of how exactly the “varying” of benefits is supposed to work.

The ethics of incentives

In principle, incentives can be framed as ‘carrots’ or ‘sticks’. Carrots are primarily rewarding, ‘sticks’ are typically penalising. The news coverage, without exception, took the policy to be about ‘sticks’ that would penalise those who exercise insufficiently with benefit reductions.  Rightly, this can be problematic: in imposing penalties, we may hold people responsible for factors that are, to a significant extent, beyond their control (think: genetics, poor environments, or social class).

Some commentators also worry about force or coercion being at play. Whether the LGiU’s proposal is coercive would depend, chiefly, on how high penalties are, and what is required as evidence of weightloss efforts. If all benefits would be lost unless a normal BMI is achieved within, say, a year, the concern clearly becomes relevant.  But it’s less obvious that “force” is being used if, for example, a program seeks to improve health by requiring gym attendance once every fortnight, and – irrespective of the actual weightloss outcome – reduces benefits by a largely symbolic value if people don’t comply.

To be clear: I favour neither of these two penalizing models. But the key is that we need to know more about the actually intended program design. While we should be alarmed about unfair penalties, shoehorning any ambiguously formulated incentive program into penalising mode denies any positive benefits to be gained from incentive programs. And it is not clear that the LGiU proposal is exclusively about penalties in the first place (note the reference to “reward”).

Jonathan Car-West, LGiU’s Director of Policy, appears to say as much, arguing that the “point is to remove barriers to people who want to get healthier and fitter.” So how would this work?  Well, benefits could also be varied by increasing levels for those who regularly use the gym.  Or perhaps bonuses could be paid for reaching self-set weight loss goals.

Coercive? Unfair? And should only those who achieve behaviour change receive a reward? What about those who try, but fail?  These and further questions matter. While many incentive programs may be ethically troubling, many others may well be acceptable and effective means of health promotion, capable of reducing social inequalities. Simply concluding that all forms of incentives are driven by nothing but disrespect for vulnerable populations can express, in itself, the worrying disposition that underlies the dictum of ‘let them eat cake’.

Whether or not incentives work is a matter of robust empirical research on a case by case basis.  Whether or not their design is ethical depends on careful thinking at the planning, implementation and evaluation phase. With the new public health responsibilities handed over to local Councils as of this year, we may see a range of natural experiments, comprising, quite possibly, a mix of the good, the bad, and the ugly.  It is right and important to warn of the dangers of using incentives as blunt and undue penalties. But we gain nothing by accusing those exploring new approaches indiscriminately at the outset. By contrast, there is much to be gained from proper design and evaluation of programs, and from discussing incentives constructively.

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4 Responses to The red rag of health incentives

  1. Bill Gardner says:

    Great post and great issue. Paul Kelleher and I debated this issue on the old blog (e.g., My view was that poor health was one of the constituents of class disadvantage, in part because of behavioural transmission across generations within families. Incentives to change health behaviour may prove to be critical to breaking this. Paul was concerned that ‘coercive’ (I’m not convinced that this the right word) incentives to, say, stop smoking, would do the most harm to those least able to bear the harm. I think we were both right…

  2. PAL says:

    Do these responsibility-based proposals mean that “force” is being used to get people to loose weight? No, the “force” is being used to get taxpayers to pay taxes – then the money is being redistributed to pay for the benefits of poor people (who are often obese and lazy). What is really happening here is that common sense is attempting to work its way into the benefits system. (Although I have to wonder about the specific idea of using the smart-cards as a gauge of gym participation since it sounds like an invitation to fraud. Why not just have a monthly BMI-measurement / weigh-in for people who are collecting benefits?) The premise of government benefits is great – that we want to help the needy and that, by helping the needy, it will help society overall. The problem with this approach is that it usually relies on the assumption that everyone who is receiving government charity is making a good-faith effort to help themselves to get off of benefits. But does everyone make a good-faith effort to help themselves? Here is another way of looking at it – does everyone exert themselves equally?

    I think it is amazing how ideas like this get flipped around by the media and the general public to make it look like the responsible people are motivated by meanness – a la the comment: “[this] is the kindly face of hatred, the result of mixing a loathing for poor people with the wider medically sanctioned disgust of fat in order to do things a bit more cheaply.”

  3. James says:

    Why are incentives being discussed with regard to benefits claimants if not because the idea is to reduce them if recipients do not comply? If it is incentives, and not penalities, why should these not also apply to middle class and rich people?
    Gyms are already humiliating places for fat people. If a few extra, much needed pounds were dependent going to these places, some people would go. Soon, gyms would have a new sterotype, the gym member who is attending because they really need a few extra quid. Imagine that was you. How would you feel knowing that people are whispering about you, they don’t appreciate your presence and their physical and societal superiority is right in your face and everyone is aware of it?

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