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‘Free-Market Breakthrough’ policy: personal preventive care budgets Despite the clear benefits that free market-based policies have had in turning Western, as  well as developing economies, into vibrant societies with increasing financial and individual  freedom, its philosophy and benefits have not really been acknowledged in the area of  public health. This is not surprising, since in its traditional sense public health addresses  issues related to the shared environment, ‘the commons’ (ref), including the prevention  and management of disease outbreaks, which generally require government-regulated, top-  down, interventions and management. However, since the 1970s public health has also  come to include the promotion of health through organized efforts and informed choices of  society, which is interpreted as the advocation of a “healthy life” through the modification  of lifestyle factors  [Public Health Ethics 2016; 9(2): 208-228], and which is susceptible to  ‘over-moralization’ of some lifestyles and behaviours [Public Health Ethics 2014; 7(2):  134:143]. Although, public health has contributed to for example the continuing increase in  the life expectancy at birth from about 70 in 1950 to about 80 in 2010  (ref), many of these  ‘lifestyle campaigns’ however, rely on “nudging” individuals towards what is considered  ‘healthy’, or ‘the best’, behaviour through penalizing them somehow (generally through  taxation or other pricing policies) when they exhibit the undesired behaviour (or, in  extreme circumstances, forbid unhealthy products in specific places; i.e. the ‘smoking  ban’, for example). This often results in criticism of what, in essence, is motivated by  “doing good”, that public health (through the state) oversteps its boundaries and resorts to  nanny-stating” and unduly interference with personal choice.   Indeed, John Stuart Mill in his well-known 1859 essay “On Liberty” draws on the example of  an unsafe bridge to discuss the problem of inference with individual liberty in the case  where there is only a danger of an adverse effect rather than a certainty, such as is the  case for all lifestyle factors:   “If either a public officer or anyone else saw a person attempting to  cross a bridge which had been ascertained to be unsafe, and there were  no time to warn him of his danger, they might seize him and turn him  back, without any real infringement of his liberty; for liberty consists in  doing what one desires, and he does not desire to fall into the river.  Nevertheless, when there is not a certainty, but only a danger of  mischief, no one but the person himself can judge of the sufficiency of  the motive which may prompt him to incur the risk: in this case,  therefore (unless he is a child, or delirious, or in some state of  excitement or absorption incompatible with the full use of the  reflecting faculty), he ought, I conceive, to be only warned of the  danger; not forcibly prevented from exposing himself to it.”  He argues in the above that ‘the state’, and here by extension public health, as not to  infringe on individual liberties, should limit itself to informing the public about the  dangers. This should be done through providing the scientific evidence of what the health  impacts of certain behaviours are, but the state should stay away from ‘forceful’  (metaphorically speaking) attempts to change behaviours. Following his argumentation to  preserve individual liberty in public health as well, a radical breakthrough with the current  top-down, population level approach to public health is required.  Moreover, there is abundant evidence that forced attempts to behaviour change are mostly  ineffective, and that people need to be motivated first in order to change  (ref). It has  been well documented, and indeed this is the basis of modern economies, that people  respond rationally to (financial) incentives, which implies that free market principles  should be equally applicable to a resource such as the health of the population. Regressive  measures such as taxation instead, are unnecessary blunt and relatively ineffective  instruments, target the poorest groups in society hardest (for example in the context of  smoking  [Am J Public Health 2004; 94(2): 225-229]), distort the market by influencing  pricing without any association to the actual production of products, and necessarily  require a large government to implement and control the policies and spend its resulting  profits  [(ref). It is important to understand that in a developed society, or indeed in any society, an  individual does not have unlimited liberties and rights, but indeed has certain obligations  as well. Contributing to society and its development should be considered one such  obligation, and as such remaining healthy to remain an active member of the working  population and/or care for children and the elderly is an obligation that one can, and  should, be expected to actively engage in. An important move away from current policies  of forcing healthy behaviours on, often unwilling, citizens, through population-based  interventions and pricing policies, would be the design of a system in which individuals  choose to modify their lifestyles themselves. The success of free markets have already  provided us with the principles to do just this; it just has not been recognized sufficiently.  A genuine ‘breakthrough’ for public health will be to open up public health to the laws of  the free market, and thereby enabling people to choose their own ‘public health care’.  This approach of responsibility to oneself and to society requires, instead of an ethically  undesirable approach of the nanny-state, instead a system of ‘Libertarian paternalism’    [Public Health Ethics 2010; 3(3): 229-238]. The policy here proposed is that of providing each person with a ‘personal public health  budget’, or more precisely a ‘personal preventive care budget’. Personal health budgets as  such are not a novel insight, and are used for example by the National Health Service (NHS)  in England to enable people to manage and pay for their won social care (ref) and in the  Netherlands for people with a disability to similarly manage their own care [(ref). The  proposed policy therefore, is not novel in concept, but would be a radical change to the  current public health approach. For example, it would come natural for many people in the  UK to spend part of their budget to improve their physical and mental health by regularly  attending a gym or by joining a sports team, while others who are not fond of physical  exercise may choose to attend a healthy cooking course. Others, who may have a  temporary stressful period at work or chaotic home situation, may decide to sign up to a  yoga or mindfulness course, for example. And also, there will be people who enjoy a  regular glass of wine which, in the proposed policy framework, would be entirely  acceptable…as long as one mitigates adverse effects with spending some additional  personal budget elsewhere; say by attending an alcohol-awareness course or by going  swimming once a week. The ‘personal preventive care budget’ could initially be funded by ringfencing of tobacco  and alcohol taxes, or from re-allocated from current budgets for prevention, and will give  each citizen a personal budget that will have to be used for ‘health’; thereby creating a  large demand side within the economic model. The market will naturally generate the  supply required to meet this demand either from existing providers or from a surge in new  start-ups addressing newly generated needs. Importantly, this will naturally create a  competitive market in which price, effectiveness, efficiency and enjoyability will be  maximized. In fact, since all new and existing providers will compete for market share,  new search and comparison systems will be required. It would be very surprising (and  uncharacteristic) if a diversity of IT entrepreneurs would not facilitate these systems (in  fact, similar frameworks already exist in the form of tripadvisor, autotrader, or Amazon, to  name a few). Ideally, this will result in a market with ‘perfect competition’ in which all   firms sell products targeting the same market, all firms are price takers, they all have a  relatively small market share, buyers have complete information about the products and  the prices charged by each firm, and the industry is characterized by freedom of entry and  exit (ref). Moreover, it also maximizes individual liberties – thus getting rid of the ‘nanny  state’ – with the public health community facilitating information about health benefits  and harms and evidence of effectiveness of the products (i.e. the courses, memberships  and other products) to the population, thereby facilitating the ‘complete information’  required for a perfect market.  It is important to highlight the ethical dilemma of this policy here: what to do with unspent  budget? Of course, there remains the option, following the argument set out by John Stuart  Mill, that people are free to incur the (health) risk if they are capable of judging  sufficiently what these risks are, and thus return unspent budget. This may be a perfectly  acceptable approach, but may not result in the improvement of social outcomes for those  segments of the population who may benefit the most, and who are disproportionally  present in the bottom third of the income distribution of the population [Marmot. The  Health Gap: The Challenge of an Unequal World. ISBN-13: 978-1408857977]. Arguably, these personal budgets should have to completely spend in a given time period. Although this  may draw criticism in that it is reverting back to “nanny-stating”, sufficient trust in the  market to develop new “products” targeted specifically at those unwilling individuals  should make it clear this criticism is unfounded. The policy described here, through the  boundaries it places on how personal budgets can be used, aims to suggest one choice over  another by gently steering individual choices in welfare-enhancing directions yet without  imposing any significant limit on available choices (i.e. a ‘Libertarian paternalism’  framework).  Other potential problems with what is in affect the opening up of a hitherto closed market  to market forces have already been identified. Experiences from the ‘personal care  budgets’ in the Netherlands mentioned above, for example, indicate that there is large  potential for fraud (ref), while also IT infrastructure problems have led to problems (ref).  Arguably though, these were teething problems whose impact would eventually be  minimized or eliminated.
If you live in the UK (or Europe) you may remember that Boris Johnson, always the  opportunist, wrote two columns for The Daily Telegraph - one pro- and one anti-  Brexit. The plan, of course, was to decide which option would be the most beneficial  to ones career and go with that (if this is new to you, the story can be found, for  example, here <link>). An alternative explanation - not very probable, but also not  impossible - was that Mr Johnson wrote the article for the sole purpose of trying to  articulate in his mind whether there was any merit in the Remain argument <link>.  Apparently, this is not a bit dodgy, but it is in fact a sign of a ‘good classical  education’ (reference). So since this is the case, I thought I may be able to do this as well. I spotted the  “Richard Koch Breakthrough Prize” hosted by the Institute for Economic Affairs  (link), and decided to bring out my inner free market zealot. I mean, how difficult  can it be: you mention free market benefits, refer to a small state, throw in some  neoliberal links, and in this particular case also mention ‘nanny-stating’, right?  Alas, more difficult than one thinks. I   did not make it to the final, and, depending on your point of view, I am now either  £50,000 poorer or I am just as rich as before. I did learn new stuff along the way  though, so it wasn’t a completely wasted journey. Anyway, I thought I’d share my entry with you. In my defence, I wrote it in one day (or technically during a flight to the Netherlands  and back). In contrast, it may also just not be very good, in which case you are more  than welcome to use it for comic relief. Lacking a classical education, I am clearly  not as good at this as Boris Johnson. There is a comments section at the end of the article, so feel free to point out where  I went wrong....   
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