Do we need a better social contract for subsidized or free insurance?

A lot of Medicaid patients in New York City are failing to take prescribed medications for diabetes, high blood pressure and high cholesterol, according to a new study. In aggregate such behaviors lead to higher costs and more strokes, heart attacks and other bad outcomes. The authors hope the findings will help local authorities develop interventions that increase adherence. That's a worthy goal.But it also got me thinking. Should free plans (like Medicaid) and subsidized ones like the private plans to be offered in health care exchanges under the Affordable Care Act come along with some sort of responsibility on the part of recipients? We could even include employer sponsored health plans in the discussion. I know it sounds like a harsh concept, but think about it. Governments and companies are straining under the weight of health care costs, and it seems we can't afford to cover everyone. But if people took better care of their health costs would drop, productivity (and tax collections) would rise, and people would be better off. The study focused on Medicaid, but it didn't compare that population with others --who may also be non-adherent.I certainly wouldn't want someone to require me to follow doctors' orders and adhere to my prescription regimen in order to get insurance. What if I don't agree with what my doctor wants me to do, and I have a good reason for it? And yet, it does seem reasonable to encourage people to follow a course that minimizes their drag on the public purse. With better technology, might it be possible to implement a plan like this?