I believe that it is both appropriate and ethical to reward patients in some manner to improve their health or adhere to a therapeutic regimen (see: A Lottery to Improve Patient Adherence to Warfarin Therapy). Such rewards may be in the form of health insurance premium incentives, participation in a lottery, or even direct cash payments. They are often relatively negligible and would hardly "widen the health gap" as suggested by the title of KevinMD's piece in the New York Times: Room for Debate blog. He republished it in his own blog (see: Paying patients to stay healthy widens the wealth gap). Here's his opinion:
In an effort to control health spending, companies are spending more money than ever to keep their employees healthy. More than half of large businesses, for instance, offer financial incentives to employees who complete smoking cessation or weight management programs. When you consider that over 40 percent of premature deaths in the U.S. is associated with smoking, inactivity or obesity, it seems like money well spent....One question, however, is whether every socioeconomic class will respond to such incentives. The patients in the studies cited above were well-educated, white, and had high incomes — hardly a representative demographic cross-section. Those with more limited economic means may not have the ability to pay for gym memberships, smoking cessation drugs, or more nutritious food. Indeed, data from several studies confirm that those in lower socioeconomic classes have poorer smoking cessation rates and diets with less whole grains, lean meats and fresh fruits and vegetables. A financial incentive for health therefore has the potential of worsening the socioeconomic disparity between people who have the resources to become healthier, and those who don’t. As a primary care doctor, it’s frustrating to see patients fail to lose weight or continue to smoke despite my counseling attempts. A monetary incentive program can indeed be a powerful motivating tool. But it has to be carefully implemented so that all patients, from every background and class, can potentially benefit.
I understand Dr. Kevin's point that the wealthy and educated often have both the means and the personal incentives to stay healthy such as access to better food and health clubs. I also want to second his idea that monetary incentive programs need to be carefully implemented so that all recipients can potentially benefit from them. My sense is that the less-wealthy will opt for cash rewards rather than, say, a discount on membership in a health club. The task ahead of us is clear, though. We need to convince the less-affluent, less-educated that robust health is a very suitable goal for them to pursue. If a lottery or some other similar incentive is useful or necessary in this regard, I say that we need to go for it.