“A healthier lifestyle and more exercise have been in the top five resolutions for years. Health insurer ASR recently launched an app to respond to this. Policyholders can receive a reward via this app if they achieve a health goal. For example, if you reach the well-known 10,000 steps per day and register it in the app, you can earn back your Fitbit (watch that counts steps) or receive a discount on the monthly premium of the supplementary insurance. Menzis also has an 'earn through exercise' program. Insurers thus distinguish on the basis of behavior. Is this ethically desirable? Is it not a threat to our solidarity-based healthcare system? Are we not pulling in a Trojan horse with lifestyle apps that reward healthy behavior?
The Dutch healthcare system is characterized by a high degree of solidarity to keep taxes and social security contributions affordable. There is risk solidarity (the healthy pay for the sick) and income solidarity (the strongest shoulders bear the heaviest burdens). There is also a fair degree of equality embedded in the system: every Dutch citizen has compulsory insurance for a broad basic package of care services determined by the government. In order to be able to claim care from the basic package, (healthy) behavior plays no role.
Accordingly, an insurer is only permitted to make a distinction between policyholders for the supplementary insurance, for which the rules are different from those for basic insurance. This has been common practice for years: for example, older policyholders pay more for the supplementary insurance than young policyholders. Insurers that link behavior and health apps to reimbursements on the supplementary insurance operate within the law.
Encouraging policyholders to live healthy lives is also commendable. It is in keeping with the National Prevention Agreement and the broader attention to 'lifestyle medicine,' where prevention through different behavior takes precedence over cure. Rewarding healthy behavior therefore also seems to meet a political desire to encourage people to live healthier lives and thus reduce health costs. Reducing rising healthcare costs is necessary to maintain our system financially and is therefore in everyone's interest.
Reward rather than punish
This means that we there is no immediate reason to fear for our system of solidarity. However, the introduction of this type of apps raises questions about possible paternalism, privacy, efficiency and the fairness of making distinctions based on behavior. The government-funded U.S. health insurer Medicaid uses so-called "responsibility contracts." If policyholders do not adhere to certain agreed conditions (such as therapy compliance, showing up at appointments with their physician), they lose the right to the stipulated reimbursements. In the Netherlands such a practice would probably not go down very well, as it would be too paternalistic.
The programs of Menzis and ASR reward users rather than punish them. However, insurers are faced with the question of whether rewarding individuals on the basis of healthy behavior is tenable, as there is by no means always a causal relationship between unhealthy behavior and higher healthcare costs. What applies at group level does not necessarily apply to individuals: not everyone with a normal weight is healthier than someone a little overweight; not everyone becomes healthier by exercising more.
Everyone benefits from more healthy Dutch people
As long as other policyholders are not directly disadvantaged by "Fitbit advantage" for eager exercisers, we think that this form of reward – such as earning back a sports watch – will not harm the solidarity of our system. The financial differences between app users and non-users are very likely to be marginal and the app and reward are not compelling. In the end, effort is rewarded rather than health as such. Moreover, behavioral change is difficult and it will probably only concern a small group, namely those who value their health to begin with.
Although caution is in order with apps of this kind and we should not be naive when it comes to privacy-sensitive data, experimenting with differentiation based on healthy behavior in supplementary insurance can help keep our solidarity system affordable. In theory, every Dutch citizen benefits from more healthy Dutch people, because we all contribute to the collective healthcare costs.”