Given a choice between paying higher health insurance premiums or walking 5,000 steps a day, 97 percent of obese patients took steps to improve their health, even those who felt they were being coerced.

It started with some controversy, but after a Michigan insurance company told obese people to walk every day or pay more for healthcare, they walked it off.

Blue Care Network of Michigan, a Blue Cross Blue Shield partner, gave obese clients an option: pay up to 20 percent more in health insurance premiums or walk 5,000 steps (roughly 2.5 miles) a day.

The move to force obese people into a fitness routine was one of the largest-scale incentive programs in the country. After one year, 97 percent of the 6,548 eligible participants met their daily average required number of steps, which were counted by a pedometer and tracked online.

Even patient critics, who initially called the move “coercive,” met or exceeded their daily walking requirements, according to researchers at the University of Michigan and Stanford University, who published their findings in the journal Translational Behavioral Medicine.

A third of those who took a satisfaction survey found the incentives—which saved some families up to $2,000 in out-of-pocket expenses—coercive. Two-thirds, however, liked the program.

“There are ethical debates around the idea of forcing someone to be personally responsible for health care costs related to not exercising, but we expect to see more of these approaches to financially motivate healthier behaviors,” senior study author Dr. Caroline Richardson, an assistant professor at the U-M Institute for Healthcare Policy and Innovation, said in a press release. “Wellness interventions like this clearly hold significant promise for encouraging physical activity among adults who are obese.”

Currently, more than one-third of American adults are considered obese, though the rate appears to be slowing, according to the latest assessment from the U.S. Centers for Disease and Control (CDC).

The CDC recently released statistics showing that only about 20 percent of American adults get the recommended 2.5 hours of cardiovascular exercise and strength training each week.

Researchers noted that the Affordable Care Act will likely expand incentive-based health programs by motivating employers and insurers to save money by encouraging healthy habits.

Kenneth E. Thorpe, chair of the Department of Health Policy and Management at Emory’s Rollins School of Public Health, recently published a study on healthcare spending. The paper, which appeared in the journal Health Affairs, found that a doubling of the U.S. obesity rate from 1987 to 2009 accounted for 10 percent of rising healthcare costs. Fifty percent of those costs were attributed to the rising prevalence of aggressive treatments.

“The current findings strongly suggest that most of the recent discussion about ways to control increases in spending, particularly among Medicare beneficiaries, may be focused on the wrong set of issues,” Thorpe said in a press release. “What is needed is a broader set of policy options focused on reducing the incidence of disease, and a better understanding of how much of the rise in treated prevalence is the result of a more aggressive treatment of chronic conditions.”

Reducing the rate of obesity is one way to reduce or prevent chronic disease. Obesity increases a person’s risk of high blood pressure, cardiovascular disease, diabetes, and certain cancers, according to the CDC.

While using coercion to improve health—as when New York City Mayor Michael Bloomberg attempted to ban large-sized sodas—will always be mired in controversy, sometimes it can provide the necessary incentive to help people make better choices.