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Wellness Incentives, Equity, and the Five Groups Problem

The Issue

Wellness incentives are an increasingly popular way for employers to encourage participation in prevention programs, which can both improve workers' overall health and reduce costs. Employees may receive a discount on premium costs for participating in an exercise, weight loss, or smoking cessation program, for instance. Or, alternatively, incentives, such as premium reductions, may be linked to meeting certain targets, like appropriate body mass index (BMI) or blood pressure. With provisions in the Affordable Care Act designed to increase employers' ability to use wellness incentives, some are questioning whether these programs may lead to equity concerns. 

What the Study Found  

The study's author, 2009–10 Commonwealth Fund Harkness Fellow Harald Schmidt, characterized employees as belonging to one of five groups: "the lucky ones," whose behavior is effortlessly compatible with wellness goals; "the yes-I-can" group, who welcome the opportunity to join an incentive program; "the I'll do-it-tomorrow" group, who may want to change behavior but choose not to for a variety of reasons; "the unlucky ones," who are unable to meet the criteria of specific incentives; and "the leave-me-alone" group, who may qualify for incentives but decide not to accept them.

Schmidt identified a number of inequities across the groups. For example, some people may receive benefits even if their behavior runs counter to the spirit of the program (e.g., those who eat in unhealthy ways and never exercise but still have favorable body mass index values). Others may face strong medical or societal constraints that make it harder to meet targets—for instance, some people with genetic mutations will always be obese, regardless of how much they exercise or diet. In other cases, people may find healthy food unavailable or unaffordable or have insufficient time to prepare it, or they may lack access and time for exercise in a safe environment.


It will be important to monitor and evaluate workers' responses to wellness incentive programs to determine whether policies should be adjusted to optimize equity. Possible solutions to inequities that arise include offering incentives that include modifications for certain individuals, offering targeted incentives to specific groups, or abandoning incentive programs altogether and using the funding for other public health initiatives.

Publication Details



H. Schmidt, "Wellness Incentives, Equity, and the Five Groups Problem," American Journal of Public Health, Jan. 2012 102(1):49–54.