How Are “Healthy Behavior” Requirements Working in Iowa?

Iowa is adding to the evidence that requiring specific “healthy behaviors” of Medicaid enrollees is an ineffective way to improve health outcomes. In 2013, Iowa got approval from CMS to expand Medicaid to adults up to 133 percent of poverty by way of an 1115 waiver. That waiver allowed the state to charge premiums to certain individuals who do not complete healthy behaviors.1

During the first year of coverage, no monthly contributions are required of any individual who is covered by this program, called the Iowa Health and Wellness Plan. To avoid paying a monthly premium after the first year, members must get one of two wellness exams—either a health or dental exam—and complete a health-risk assessment. If a member does not complete both healthy behaviors during the first year, they are charged monthly premiums of $5 or $10 the subsequent year, depending on income. Individuals earning less than 50 percent of poverty ($5,835 per year for an individual or $7,865 for family of two) are not charged premiums at all, nor are members of other special populations.

Four years into implementation, results of the healthy behaviors requirement are lackluster at best. Despite the prospect of paying a premium, few members of Iowa’s plan who are subject to the requirement go on to complete the exam and assessment. The program rules are complicated, so members may not even know about the requirements. In September 2017, a total of 151,453 adults were enrolled in the expansion program, and among them, 40,400—just over a quarter—were subject to premiums.2 (Approximately 43,000 were exempt because of income or other special status and 73,000 were still within their initial year of coverage.) Only 10,475—just over a quarter of all those subject to premiums—had completed the healthy behaviors and had their premiums waived.

During that month over 1,300 members were sent to collections and over 800 were disenrolled for failure to pay premiums within a 90-day grace period.3 These numbers are expected to grow.

A 2016 interim evaluation of the program by the University of Iowa Public Policy Center found similarly “suboptimal” completion rates at the time, noting that “the combination of a general lack of awareness and understanding about the program at the enrollee and provider level have stunted the program’s ability to achieve significant participation.” Nine in 10 members did not even know their premiums could be waived if they completed the healthy behavior requirement.4

How Are “Healthy Behavior” Requirements Working in Iowa?

Healthy behaviors requirements create real challenges for  both the Medicaid program and clinic staff—to know the requirements, to administer exams and assessments and report compliance, to track compliance and bill and process payments—for what amounts to very small impact in the scheme of Iowa’s Medicaid program. About a quarter of the state’s 600,000 Medicaid enrollees are part of the expansion program; of that expansion group only about a quarter are subject to the healthy behaviors requirement. Of that group only about a quarter actually complete it. Each month the state sends members to collections—and makes it more difficult for them to make ends meet—for failure to pay monthly premiums of just $10.

Iowa’s low participation rate should come as no surprise. It fits with a growing body of evidence that efforts like this one—whether implemented in state Medicaid programs or in private workplace initiatives—are largely ineffective, showing at best evidence of limited, short-term compliance, but little of long-term health improvements. For Medicaid specifically, research shows that limiting coverage or access to services as a penalty for failing to complete healthy behaviors or pay premiums actually harms patient care and leads to increased use of emergency services.5

Despite this track record of lack of success, state officials are continuing down this path. Iowa decided last year to expand the healthy behaviors program to the Medicaid dental benefit for the entire adult (19 and older) population, not just those covered by expansion. As of July 1, 2017, they were integrated into a single, unified dental program. All enrollees receive comprehensive dental benefits during the first year of enrollment. In subsequent years, members must complete healthy behaviors in order to receive full dental benefits.

Instead of expanding complicated programs that add red tape and administrative burden, the state should focus on reducing the barriers that make it difficult for Iowans to access care and be healthy in the first place.

Mary Nelle Trefz is the health policy associate at the Child and Family Policy Center. 

  1. Members who declare hardship, the medically frail, American Indians/Alaska Natives and members of the Health Insurance Premium Payment Program.
  2. Iowa Wellness Plan Quarterly Report: 1115 Demonstrative Waiver:
  3. ibid.
  4. Health Behaviors Incentive Program Evaluation: Interim Report, University of Iowa Public Policy Center, University of Iowa College of Public Health, March 2016:
  5. For a discussion of workplace initiatives, see Gingerich SB, Anderson DR, Koland H. Impact of financial incentives on behavior change program participation and risk reduction in worksite health promotion. Am J Health Promotion. 2012 Nov-Dec; 27(2):119-22. For discussion of Medicaid initiatives, see Hannah Katch and Judith Solomon, Are Medicaid Incentives an Effective Way to Improve Health Outcomes? Center on Budget and Policy Priorities, January 2017.