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ABSTRACT Health behavior incentive programs are increasingly common in Medicaid programs nationwide. Iowa's Healthy Behaviors Program (HBP) requires Medicaid expansion enrollees to complete an annual wellness exam and health risk assessment or pay monthly premiums to avoid disenrollment. The extent to which the program reduces the use of hospital-based care and lowers health care spending is unknown. Using data for 2012-17 from Medicaid and for 2014-17 from HBP, we evaluated changes in use and spending associated with HBP participation. Compared to nonparticipants, HBP participants were less likely to have an emergency department visit or be hospitalized (by 9.6 percentage points and 2.8 percentage points, respectively) but had higher total health care spending ($1,594). Meanwhile, Iowa's Medicaid expansion was associated with increased use and spending independent of HBP participation-that is, applying to both participants and nonparticipants. Overall, our findings suggest that the HBP was associated with substantial reductions in hospital-based care but increased health care spending.
In 2014 Iowa expanded eligibility for Medicaid using a Section 1115 waiver to create the Iowa Health and Wellness Plan. People with incomes at or below 100 percent of the federal poverty level were enrolled in the Wellness Plan (essentially, the traditional Medicaid state plan), while those with incomes of 101-138 percent of poverty were enrolled in the Marketplace Choice Plan (in which Medicaid subsidized the cost of private coverage purchased through Iowa's health insurance Marketplace). Iowa's Medicaid expansion has been discussed in greater detail elsewhere.1
A distinguishing characteristic of both plans- which were combined and then transitioned to managed care in 2016-is the Healthy Behaviors Program (HBP). The program was designed to incentivize personal responsibility for the use of preventive care by requiring enrollees to complete an annual wellness exam and health risk assessment or pay monthly premiums. While people with incomes below 51 percent of poverty are exempt from the premiums, those with incomes of 51-100 percent of poverty pay a $5 monthly premium, and those with incomes of 101-138 percent of poverty pay a $10 monthly premium. Moreover, people in the highest income group canbe disenrolled for premium nonpayment.
Such personal responsibility requirements expand public insurance coverage while embracing market-based reforms.2 Eighteen states are operating-or have been approved to operate- Medicaid health behavior incentive programs, but...