Behaving well in elementary school could reduce smoking in later life. At least, that's what Trillium Community Health Plan hopes, and it's putting money behind the idea.
Danebo Elementary in Eugene, Ore., is one of 50 schools receiving money to teach classes while integrating something called the "Good Behavior Game." Teacher Cami Railey sits at a small table, surrounded by four kids. She's about to teach them the "s" sound and the "a" sound. But first, as she does every day, she goes over the rules.
"You're going to earn your stars today by sitting in the learning position," she says. "That means your bottom is on your seat, backs on the back of your seat. Excellent job, just like that."
For good learning behavior, like sitting quietly, keeping their eyes on the teacher and working hard, kids get a star and some stickers.
Railey says the game keeps the kids plugged in and therefore learning more. That in turn makes them better educated teens and adults who're less likely to pick up a dangerous habit, like smoking.
The Washington, D.C., nonprofit Coalition for Evidence Based Policy says it works. It did a study that found that by age 13, the game had reduced the number of kids who had started to smoke by 26 percent — and reduced the number of kids who had started to take hard drugs by more than half.
The fact that a teacher is playing the Good Behavior Game isn't unusual. What is unusual is that Trillium is paying for it. Part of the Affordable Care Act involves the federal government giving money to states to figure out new ways to prevent people from getting sick in the first place.
So Trillium is setting aside nearly $900,000 a year for disease prevention strategies, like this one. Jennifer Webster is the disease prevention coordinator for Trillium Community Health, and she thinks it's a good investment.
"The Good Behavior Game is more than just a game that you play in the classroom. It's actually been called a behavioral vaccine," she says. "This is really what needs to be done. What we really need to focus on is prevention."
Trillium is paying the poorer schools of Eugene's Bethel School District to adopt the strategy in 50 classrooms.
Trillium CEO Terry Coplin says changes to Oregon and federal law mean that instead of paying for each Medicaid recipient to get treatment, Trillium gets a fixed amount of money for each of its 56,000 Medicaid recipients. That way Trillium can pay for disease prevention efforts that benefit the whole Medicaid population, not just person by person as they need it.
"I think the return on investment for the Good Behavior Game is going to be somewhere in the neighborhood of 10 to one," Coplin says.
So, for each dollar spent on playing the game, the health agency expects to save $10 by not having to pay to treat these kids later in life for lung cancer because they took up smoking.
Coplin concedes that some of Trillium's Medicaid recipients will leave the system each year. But he says prevention still makes medical and financial sense.
"All the incentives are really aligned in the right direction. The healthier that we can make the population, the bigger the financial reward," he says.
The Oregon Health Authority estimates that each pack of cigarettes smoked costs Oregonians about $13 in medical expenses and productivity losses.
Not all the money Trillium is spending goes for the Good Behavior Game. Some of it is earmarked to pay pregnant smokers cold, hard cash to give up the habit. There's also a plan to have kids try to buy cigarettes at local stores, then give money to store owners who refuse to sell.
This story is part of a reporting partnership with NPR, Oregon Public Broadcasting and Kaiser Health News.