I like the concept of a “personal responsibility contract”, but the NEJM takes exception:

There are well-understood reasons why Medicaid beneficiaries have poorer health indicators and higher rates of noncompliance than many other patients. Poverty results in reduced access to child care, transportation, healthful foods, and exercise facilities, as well as lower literacy, more life crises, and higher rates of untreated psychiatric illnesses. People with fewer experiences of success are less likely than others to believe that they can change their health status. This plan asks the most vulnerable population to do more with less ability to accomplish what we ask of them.