When Bruce Hodgins went to the doctor for a checkup in Sioux City, Iowa, he was asked to complete a lengthy survey to gauge his health risks. In return for filling it out, he saved a $10 monthly premium for his Medicaid coverage.

In Las Cruces, N.M., Isabel Juarez had her eyes tested, her teeth cleaned and recorded how many steps she walked with a pedometer. In exchange, she received a $100 gift card from Medicaid to help her buy health care products including mouthwash, vitamins, soap and toothpaste.

Taking a cue from workplace wellness programs, Iowa and New Mexico are among more than a dozen states offering incentives to Medicaid beneficiaries to get them to make healthier decisions — and potentially save money for the state-federal health insurance program for the poor. The stakes are huge because Medicaid enrollees are more likely to engage in unhealthy practices, such as smoking, and are less likely to get preventive care, studies show.

For years, private employers and insurers have used incentives to spur employees and members to quit smoking, lose weight and get prenatal care, although the record of those programs for changing long-term behavior is mixed, studies show. “Financial incentives are effective at improving healthy behaviors, though the effect of incentives may decrease over time,” said a report last year by the Center for Health Care Strategies, a research group based in Hamilton, N.J.

Another analysis published this month in the journal Preventive Medicine, which looked at 34 studies, found that workplace and other incentives can change health behaviors in the short term, but the effects dissipated once the incentives were taken away.

The Affordable Care Act is behind the latest push of wellness incentives in Medicaid.  Besides Iowa and New Mexico, several other states that have expanded Medicaid under the health law have incorporated such incentives, including Indiana, Pennsylvania, New Hampshire and Michigan. Montana, which is about to become the 29th state to extend Medicaid, also plans to include such incentives.

“People are looking for some creative ways to pass Medicaid expansion and incentivizing healthy behaviors is pretty palatable to both conservatives and liberals,” said Maia Crawford, program officer of the Center for Health Care Strategies. “It’s a potential win-win because of the potential for cost savings and health improvement.”

But getting them to participate in incentive programs can be challenging. For example, an Idaho program that offered a $100 voucher to entice Medicaid recipients to lose weight or quit smoking attracted less than 2 percent of eligible adults after two years.

Among the biggest obstacles is simply getting the word out to enrollees, Crawford said.  But there are other issues, too: Poor people are less likely to understand how the incentives work and to face transportation and other barriers to get to doctor appointments or educational classes that are part of the program.

‘Long Way To Go’ To Learn What Works

Little is actually known about what types of incentives get people’s attention or help change their behavior, said Jean Abraham, associate professor of health policy and management at the University of Minnesota. It’s not clear, for instance, whether rewards are more effective in prodding people to take a concrete step, such as getting a colonoscopy or a mammogram, rather than in changing long-term behaviors, such as smoking. “We have a long way to go to understand what’s most effective,” she said.

The health law sought to get answers to some of those questions by including $85 million to test incentives in 10 state Medicaid programs.

States started the studies in 2012 and 2013 and some are struggling to get participants. Connecticut, for instance, has enrolled only half of the 6,000 people it sought for a smoking cessation program. The program pays Medicaid recipients as much as $350 in gift cards over a year for participating in smoking cessation counseling, using a counseling phone line and having a breathalyzer test showing they haven’t recently smoked. The $10 million, three-year study will compare that group’s health costs against those of a control group of Medicaid recipients who smoke but received no help.

Other states that received funding are California, Hawaii, Minnesota, New York, Nevada, New Hampshire, Montana, Texas and Wisconsin.

Separate from the health law, one of the largest incentives program is New Mexico Medicaid’s Centennial Rewards, which gives most of the state’s 600,000 recipients the chance to earn points to buy health care items.

They gain points each time they engage in a healthy behavior, such as getting a checkup or seeing a dentist. So far, only about 45,000 have registered and only half of those have redeemed points for gift cards.

New Mexico officials say they are not disappointed. “It is not only a new program for us, but a new concept for most Medicaid programs,” said Medicaid spokesman Matt Kennicott.

‘I’ve Never Felt This Good’

 Juarez, 57, of Las Cruces, said the program has motivated her to walk every day at the mall where she works as a hair stylist and helped bring down her blood sugar levels.

“I’ve never felt this good,” she said. “This program motivates me to do more — it’s not so much the money as it’s the improvement in my body.”

Charles Milligan, who until last month was senior vice president of Presbyterian Health Plan in New Mexico, another Medicaid plan, said he’s seen an increase in members seeking preventive care, such as diabetes screenings and prenatal care. “The rewards program helps us engage with our members,” he said. Still, only about 30,000 of their 200,000 members have registered for it.

Iowa has also faced challenges getting Medicaid enrollees to complete the wellness exam and health risk assessment survey — even though some will have to pay a $5 or $10 monthly Medicaid premium if they don’t.  About 19,500 of the state’s 125,000 enrollees have faced the potential penalty. Of those, about a third completed the wellness exam and assessment.

“The goal is to get people involved and to take a more active role in their own health and we are impressed with what we have achieved,” said Andria Seip, Iowa Medicaid’s Affordable Care Act policy manager.

Hodgins, who enrolled in Iowa Medicaid in January, said he’s glad his community health center advised him about the wellness exam and health survey —not because it saved him money but because he found out that he had high cholesterol and blood sugar, which he’s now working to bring under control.

“I’ve been blessed with decent health for 57 years,” said Hodgins, who recently started a delivery company and doesn’t mind the state prodding him to get examined. “I have to be responsible for my own health. That’s my obligation.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Affordable Care Act payment model saves more than $384 million in two years, meets criteria for first-ever expansion.

For many older people and their families, particularly those dealing with conditions such as Alzheimer’s or cancer that often require long-term, pricey medical care, running out of money is a nagging concern.

Families are right to be worried, according to a new study that analyzed data from nearly 1,200 people who died between 2010 and 2012 and who participated in the University of Michigan’s ongoing national Health and Retirement Study.

Among people who were age 85 or older when they died,  one in five had no assets left apart from their homes, and 12 percent had no assets left at all, only income from sources such as Social Security or pensions. The analysis by the Employee Benefit Research Institute found that those who died younger were even worse off. Among people who died between age 50 and 64, 30 percent were without assets and 37 percent had only their homes.

Families where someone died at a relatively young age tend to have lower incomes and assets, says Sudipto Banerjee, a research associate at EBRI and the study’s author.

“People with lower assets and income tend to be in worse health,” he says, noting that many studies have found a correlation between health and wealth, showing that wealthier people tend to live longer than poorer people.

The EBRI study didn’t examine the reasons people’s finances were often depleted at death, so there’s no way to know the extent to which health care, specific illnesses or insurance coverage played a role.

Financial experts have long cautioned that medical care for seniors is an expensive concern, partly because some care related to Alzheimer’s disease, for example, is not covered by insurance. In addition, even with Medicare coverage and private insurance, seniors still can face large out-of-pocket expenses for major illnesses. According to an estimate by Fidelity, a 65-year-old couple who retired in 2014 would need $220,000 to cover their health care costs during retirement.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

As mental health professionals, policy makers and advocates focus on taking steps to mend the fragmented mental health care system, the role of patients and their friends and families is sometimes overlooked.

That’s why the American Psychiatric Association is releasing a first-of-its-kind book to decode in plain English the Diagnostic and Statistical Manual of Mental Disorders – a guide for mental health providers that is also used to determine insurance coverage. The resource, Understanding Mental Disorders: Your Guide To DSM-5, includes in-depth explanations of risk factors, symptoms and symptom management, treatment options and success stories.

This gets at one of APA’s reasons for releasing this volume — to help create a more accurate picture of what a particular illness or disorder might involve.

Jeff Bornstein, a psychiatrist and spokesman for APA, said empowering patients with a better understanding of what they are facing will enable them to better advocate for themselves.

“Sometimes when there is a disagreement with a managed care company, the clinician speaks on behalf of the patient,” Bornstein said. ”But it’s[also] helpful to have family [members] or the patient talk and say ‘I’m telling you, I have this symptom, it’s part of diagnosis X, Y and Z.  Why are you not letting me have the treatment I need?’”

Former Rhode Island Congressman Patrick Kennedy, a mental health advocate, said the book is designed to help families and patients overcome stigma and get more involved in treatment. He said it would have helped him in his own experience with bipolar disorder and alcoholism. “I was the last one to know I had a problem, and that’s often the case for those of us in crisis. … The people around me would have benefited from this,” he said at an event marking the book’s launch.

When people think they may have an issue, or are faced with a diagnosis, they often go to the Internet where misinformation and “horror stories” are widespread, said Paul Gionfriddo, president of mental health advocacy group Mental Health America. “This [book] lays out in clear terms [what a mental disorder diagnosis means] so we don’t have to live in fear of the unknown.”

Take the experience of Melanie Carlson, 33, who suffered a psychotic episode in 2007 when she was 25.  She ended up in a hospital, frightened and confused.

“It was a very traumatic incident. I was afraid of my own thoughts and what I was capable of,” said Carlson, who lives outside Ann Arbor, Mich., and manages her bipolar disorder with medication, exercise, therapy and abstaining from alcohol. But for almost a year-and-a-half she was in denial and refused treatment, mainly because she says her only knowledge of her condition came from media reports about high-profile, often violent events involving mental illness.

She says having more straight-forward information could have helped her understand that she could take care of her disorder and still live a normal life – with a job, friends and family.

“It felt like a hopeless situation,” Carlson said, who is now a social worker helping chronically homeless people get housing. “If I’d had a resource that explained my symptoms … and explained how complying with treatment could produce long-term stability I would not have been … resistant.”

It’s all part of the steady process of removing the taboo from treatment, said Jorge Petit, a psychiatrist and founder of Quality Healthcare Solutions Group, a health care and behavioral health consulting firm in New York City. “It’s no different than diabetes and hypertension — it requires awareness and understanding of how to maintain wellness and not to relapse,” he said.

However, he added that the playing field is still not even.  “It’s hard for people to call the insurance company and say, ‘Why are you sending me a prior authorization notice? It’s the same as having a medical issue.’”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.