Public health has moved from the public good component of health to everything related to health and, then, to everything related to society. If we take public health in its wide, total, social sense, it presumably explains or justifies much of the regulatory state. Virtually all state activities contribute directly or indirectly to some citizens’ “physical, mental and social well-being” (as the World Health Organization’s definition says). Public health requires social engineering, which cannot be achieved without controlling the lifestyles that the Philosopher King doesn’t like. Controlling lifestyles cannot be done without regulating the businesses that would allow people to satisfy their sinful preferences, and without preventing these people from circumventing the controls through black markets or other violations of government regulation.Lemieux points to the difference between public health as it was conceived a couple of centuries ago, and its rather broader current scope. The galling thing is that classical public health provided true public goods: things that really can well be provided by the state:
Until the 18th century, public health appeared to be concerned with preventing communicable diseases through sanitation and the isolation of epidemics victims. In this sense, public health can be viewed as a response to the negative externality of contagious diseases or, alternatively, as the public good of preventing their spread.Indeed. Gordon Tullock often chided the anarchists in the classroom by asking how they'd deal with quarantine in case of epidemic. Vaccination, sanitation, and reporting on and dealing with outbreaks of contagious disease seem eminently worthy activities. Public health has expanded substantially since then.
But I'm not sure that Lemieux quite nails the problem. He points to the growth in spending on healthcare by the government, to voter ignorance, and to bureaucratic incentives within the healthcare sector as generating the increase. But if rational ignorance were the main problem, then making voters aware of the growing paternalistic regulatory state would be enough to stop it. Instead, many voters are quite supportive of the growing paternalism. And if we take an interest group story, why has the public health bureaucracy and associated interest groups been able to run its rolling maul on consumers and affected producer groups? A standard Olsonian concentrated interests story would explain why the bureaus beat consumers, but wouldn't as easily explain nontrivial voter support for regulatory interventions curbing their preferred consumption behaviours, nor would it explain why the bureaus and public health interest groups beat the affected industry groups.
We're getting closer when Lemieux writes:
Contemporary public health cannot be pursued without lifestyle controls, and lifestyle controls cannot be imposed without harming some real individuals. The lifestyles hit today are often different from those targeted in the past by social hygiene, racial hygiene, or the eugenic movement. Often, though not always, the targeted lifestyles belong to individuals among the poorest social classes. Sometimes the regulatory controls are accompanied by entitlements that make them easier to swallow and to enforce. The victims of public health lifestyle controls are numerous. Gerard Hastings admits that “the behaviours that [public health workers] all address comprise a typical Saturday night out for large sectors of the population.” (Hastings 2012, p. 2)Here's my take on it.
Health care takes up an increasing part of government budgets due to an expansion in the proportion of basic healthcare covered by governments rather than privately, due to demographic change, and due to increased cost of dealing with those illnesses that were once untreatable. Health budgets are then really salient. Voters are always looking for no-cost ways of saving money. All those political parties that promise vast savings by identifying "efficiencies" and stamping out waste? They're appealing for a reason.
Next, put in bogus "social cost" measures that work to convince voters that drinkers, smokers, the obese, and generalised "others" are to blame for substantial parts of the health budget, rather than the ageing boomer cohort. The vast majority of the costs tallied in these studies, when not simply fabrications of double-counting, are costs smokers, or drinkers, or the obese, impose on themselves. But they're presented to the public as "costs to the country" rather than "costs incurred by the obese, smokers, and heavy drinkers." Sure, they're all members of the public too. But the number of times I've seen people cite these social cost figures as though they're costs to the health care system or to the government more generally - I call it a deliberate effort to confuse the public on the part of the public health movement. When challenged, they'll admit that the figures are mostly costs borne by the consumers of unhealthy products. But it's pretty rare to see that in the press releases put out by the health lobby. Instead, it's all framed as "costs to the country", with the implicit and never stated footnote being "costs to the country mostly consist of costs borne by people in the country who are heavy drinkers and smokers."
Paternalistic interventions to reduce others' drinking and smoking and eating, and especially when combined with stock images of lower-class obese people, or of drinking teenagers, then gain public support because they seem a free-money deal, like abolishing the budget deficit by identifying "efficiencies". Why not support interventions when those other people are costing you so much through effects on the public health system and the tax system? Except that drinkers aren't really costing others all that much, smokers are a boon to the public purse, and who knows which way the true fiscal effects of obesity run?
Beware the Stalin Gap.
Update: I think space constraints in the symposium issue hit Pierre's article. Here's some of his prior work on the topic in Regulation and at EconLib.