Public Health Public Policy Regulation

Nudge or Nanny State?

An interesting article in the N.Y. Times “Upshot” section by Austin Frakt argues that federal efforts to nudge people towards healthier behaviors may be doomed to fail.

$100 billion dollar health care package…encourages exercise by treating gym memberships as tax-deductible medical expenses…[a]nd it would permit the use of flexible spending accounts and health savings accounts to buy sports equipment. In other words, the spending package is intended to nudge Americans to exercise more and to get a better handle on their finances

The authors call rules that require individuals to make active chooses to enage in health behavior “active” policies. The authors cite some of the issues that workplace wellness programs have face:

Some people will benefit from active policies, but they’ll disproportionately be those who would have done what the policies encourage anyway. That’s a big part of why wellness programs — which provide financial incentives for healthy activities or preventive care — don’t work, as numerous studies have shown

If active policies don’t work, then what does?

The evidence suggests it’s passive policies. These are programs that don’t require individual action; you’re not expected to add another task to the to-do list. Examples include default enrollment in a 401(k); in the health realm, they are public health efforts like water fluoridation and air quality improvement.

While these are great examples, not every part of life is amendable to passive policies. One solution to have people eat healthier is to automatically give them a private chef, or more realistically provide cafeterias with free healthy food for all. However, I don’t think socialized food is the way to go to get people to eat healthy.

I think what the Frakt and Benavidez are arguing, however, is more that the government should give up trying to get people to improve their own health if costs of doing so are high and unlikely to success. If the government can focus on passive polices that improve health with little individual effort (e.g., sanitation improvement, pollution regulation, water quality, cigarette taxes), these are more likely to succeed.

Still, there is a philosophical dilemma. Some would argue that these policies are nudging individuals towards health decisions (e.g., smoking less); others would argue that this is the government acting as a nanny state. What are your thoughts?

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