Speaking from the easy chair where he spends his days in a small wooden house near this small Appalachian town, his left trouser leg folded by a safety pin where a limb was lost to diabetes, he lighted another cigarette. 

Mr. Johnson, 61 and a former garbage collector, takes insulin and goes to a clinic once a month for diabetes checkups. Taxpayers foot the bill through Medicaid, the federal-state health coverage program for the poor. 

But when doctors urged him to mind his diet, “I told them I eat what I want to eat and the hell with them.” 

“I’ve been smoking for 50 years — why should I stop now?” he added for good measure. “This is supposed to be a free world.”

Ignoring doctors’ orders may now start exacting a new price among West Virginia’s Medicaid recipients. Under a reorganized schedule of aid, the state, hoping for savings over time, plans to reward “responsible” patients with significant extra benefits or — as critics describe it — punish those who do not join weight-loss or antismoking programs, or who miss too many appointments, by denying important services.

The incentive effort, the first of its kind, received quick approval last summer from the Bush administration, which is encouraging states to experiment with “personal responsibility” as a chief principle of their Medicaid programs. Idaho and Kentucky are also planning reward programs, though more modest ones, for healthful behavior.

In a pilot phase starting in three rural counties over the next few months, many West Virginia Medicaid patients will be asked to sign a pledge “to do my best to stay healthy,” to attend “health improvement programs as directed,” to have routine checkups and screenings, to keep appointments, to take medicine as prescribed and to go to emergency rooms only for real emergencies. 

“We always talk about Medicaid members’ rights, but rarely about their responsibilities,” said Nancy Atkins, state commissioner of medical services.

“We’re in an Appalachian culture where there’s a fatalism, and many people don’t go in for checkups or preventive services,” Ms. Atkins said, noting that West Virginia had some of the country’s highest rates of obesity, smoking, heart disease and diabetes. “We want to reach people before they get chronic and debilitating diseases that will keep them on Medicaid for the rest of their lives.” 

Those signing and abiding by the agreement (or their children, who account for a majority of Medicaid patients here) will receive “enhanced benefits” including mental health counseling, long-term diabetes management and cardiac rehabilitation, and prescription drugs and home health visits as needed, as well as antismoking and antiobesity classes. Those who do not sign will get federally required basic services but be limited to four prescriptions a month, for example, and will not receive the other enhanced benefits.

In future years, those who comply fully will get further benefits (“like a Marriott rewards plan,” Ms. Atkins said), their nature to be determined but perhaps including orthodontics or other dental services. 

No one questions that West Virginia, more than most other states, needs more healthful lifestyles and better primary and preventive care. But the new plan has stirred national debate about its fairness and medical ethics. A stinging editorial in The New England Journal of Medicine on Aug. 24 said it could punish patients for factors beyond their control, like lack of transportation; would penalize children for errors of their parents; would hold Medicaid patients to standards of compliance that are often not met by middle-class people; and would put doctors in untenable positions as enforcers. 

“What if everyone at a major corporation were told they would lose benefits if they didn’t lose weight or drink less?” said a co-author of the editorial, Dr. Gene Bishop, a physician at Pennsylvania Hospital in Philadelphia.

Denying mental health aid to those who do not sign seems especially counterproductive, Dr. Bishop said in an interview.

“If you think about the people least able to do simple things like keep appointments and take all their medications,” she said, “people with mental health and substance abuse problems are right up there.” 

Judith Solomon of the private Center on Budget and Policy Priorities, in Washington, said that the plan was unlikely to save West Virginia money or improve patient health and that it carried “the risk that some very vulnerable people may be denied health care they need.”

But Ms. Atkins, the state health official, said critics had misunderstood the plan, which, she said, simply “gives people rewards and incentives to improve their health.”

Here in Lincoln County, as in the two other counties in the pilot phase, there is a federally subsidized primary-care center that is a leader in developing “care management” programs, nudging people into preventive services and lifestyle changes voluntarily.

The Lincoln Primary Care Center in Hamlin, a town of 1,500 an hour’s winding drive west of Charleston, is a showcase for preventive medicine, with its own fitness center, an exercise physiologist, a dietary adviser and a mental health counselor — resources that are lacking in many rural clinics. The center stays open until 9 most nights, making it easier for sick people to come in for urgent care rather than driving to distant emergency rooms. 

A former tobacco-growing area, Lincoln is one of the state’s poorest counties, with a population of 22,000 scattered through the hills. About 9,000 use this care center, a majority of them uninsured or on Medicaid, said Brian Crist, the chief executive. 

Some doctors here and throughout the state were initially alarmed by the new rules, which were delayed six months for discussions and fine-tuning. But state officials appear to have allayed some fears, and many doctors are now taking a wait-and-see attitude.

Officials have offered assurances, for example — and Ms. Atkins emphasized in an interview — that doctors will be able to provide medically necessary drugs and care to children even if their parents have not followed the agreement. This was not clear in the written plan and may be needed in any case, critics said, to comply with federal law. 

Dr. Syem B. Stoll, a physician at Lincoln, said the clinic’s three-year-old effort to promote lifestyle changes for patients with hypertension, obesity, diabetes and other problems had already made a difference for many. 

“We’re doing a lot more than just giving people pills and sending them home,” Dr. Stoll said. 

Of the new Medicaid rules, he said: “My interactions with patients won’t change — I am who I am. But giving people responsibility and initiative is the way to go.” 

In interviews with several residents of the Hamlin area, including Medicaid recipients, none said they had heard about the new rules.

When they were outlined for Mr. Johnson, the cantankerous diabetic, he said he had no intention of participating. “Hell, no,” he said. “I wouldn’t sign an agreement like that.” Somewhat incongruously, he appears to be off the hook: as a disabled person he will be exempt under the rules. 

Brittney Lovejoy, 18, earns $5.40 an hour at the Burger King here and is a Medicaid patient at the Lincoln center, as are her 4-year-old daughter and 6-month-old son. “I guess I’ll have to sign it,” she said after hearing a description of the new agreement, apparently unenthusiastic about the idea though not foreseeing any major problems.

But Karen Ball, 35, a night manager at the Burger King, said she did not think the program was fair. Though Ms. Ball is uninsured herself — she uses the Lincoln clinic rarely, paying reduced fees — her three sons are on Medicaid. They go for their required annual checkups, so the agreement should pose no problem for them. 

Still, “some people can’t afford the transportation to go to these programs,” she said, “between the price of gas and the lack of jobs here — and what jobs there are pay minimum wage.”