This post appears on the National Journal's Health Care Experts Blog where you can also see what other health policy analysts have to say about ways to promote wellness through health reform.

This is another example for which both God and the Devil are in the details. No one disputes that some behavioral choices -- smoking, diet, regular exercise, age and condition-appropriate screenings -- affect health status, expected health costs, and therefore, our collective average premiums. It seems perfectly reasonable, especially to economists and to those who make good choices already, to use incentives to encourage socially responsible choices and to discourage those that impose costs on others. At the same time, smoking is addictive and extremely hard to quit for some people who really want to, obesity can be caused or exacerbated by genetics and often comes with co-morbidities like depression that make financial incentives ineffective, and some people can only afford to live in neighborhoods with no stores that sell fresh fruits and vegetables and with little safe walking space. So how to reward good behavior without punishing the unlucky?

Two thoughts occur to this economist. First, if everyone in the country got their insurance through an exchange and/or pure community rating across all people and "groups" were the norm, then employers would not worry about differential health costs of their workers' vs. others (they would still care about average costs, appropriately) and one great fear of workplace discrimination would be erased. So we should develop reform proposals that move us toward this type of insurance system eventually.

Second, and more practically for the short run, why not allow reasonable and income-related incentives for good choices, or penalties for bad, but acknowledge our less than perfect knowledge about exactly how to accomplish smoking cessation and weight-loss etc., (otherwise, wouldn't we all be skinny and no one would smoke?) so that a person is exempted from the penalty if they engage in the remedy program chosen by the employer or health plan in the exchange, and such a program must be made available where behavioral incentives are in place  This should encourage plans and employers and the government to hone and disseminate practical research on what behavioral programs work best, it will encourage people to take behavioral steps to address their problems rather than simply punish those who "fail" to cure themselves, and it will punish those who refuse to try and help themselves.  That last is the behavior that breeds resentment among those who feel like they are otherwise forced to pay more for those who do not take proper care of themselves. Compassion demands we present alternatives and limit the penalties, but basic fairness says it is ok to expect effort in exchange for cross-subsidies from the community.