Medium-Handed Public Health

Ezra Klein has his doubts about using public policy to try to improve the healthiness of American lifestyle:

Meanwhile, the reason doctors are constantly prescribing statins along with admonitions to exercise and eat better is because using public policy to change diet and exercise habits is really, really, really hard, unless you're prepared to be very heavy-handed (i.e, outlawing trans fats in restaurants, setting portion limits, etc).

I'm not so sure about that. The sense that public policy won't work here seems to me to be driven by a failure to look at things at the margin. I have absolutely no idea what kind of reasonable policy measure would get 90 percent of Americans to engage in 30 minutes of vigorous aerobic exercise per day, but I think it's pretty easy to think of policy measures that would somewhat increase people's propensity to walk or ride a bike rather than drive their car. These things -- a carbon tax, say -- would be politically difficult to achieve, but so would comprehensive reform of the American system of health care finance. They would also achieve important goals related to climate change.

What's more, while I don't have a good twenty point plan to link to off the top of my head, that's in large part because there isn't this army of diet-and-exercise policy wonks at DC's think tanks churning out the policy papers. The progressive policy community is awash in health care finance ideas because that's what donors have decided to fund. At some points years ago, someone or other decided to put a lot of emphasis on getting people to stop smoking, and they've proven over the years to be quite creative about dreaming up and endless series of ever-more-restrictive policies to push for, each of which is sufficiently mild on its own terms as to be capable of securing political support.

Comments

It's very, very healthy to live in a big city with a good public transportation system. If the city makes it cost- and time-effective to walk and take trains and buses, people do it, and it's a great boon to their lifestyle. If more cities and states invested in real public transportation, it would have a big effect.

Posted by DivGuy | May 29, 2007 9:09 AM

In addition to transportation changes, re-arranging the farm bill, as Michael Pollan's been popularizing (and starting to call it a food bill), would probably also have a decent impact.

Also, no support for [strike] tags? That is a serious impediment to humor.

Posted by greg claxton | May 29, 2007 9:17 AM

The formulaic "30 minutes of aerobic exercise" is just crap. A combination of walking more and consuming less trans fat would do the trick. Trans fat is the great identifiable bugbear here. Obesity went through the roof immediately after its use became widespread. That wasn't an accident. If people simply walked more and didn't eat so much trans fat we could go back to being the lard ass country of my youth rather than the horrific walking mounds of adipose of the last 15 years.

Posted by Jeffrey Davis | May 29, 2007 9:24 AM

Ummm, not to bash you too much Matt Yglesias, I think you're a fine writer, but you haven't thought this one through. There are reams of public health policies generated in other countries over the years. Overall, the most successful ones have been found in Scandinavia.

And, politically? Just about all of them are really politically difficult to implement in the US. It's well known, for instance, that mandating healthy meals for children in schools and throwing out the vending machines has the potential to make a massive public health impact.

It's barely even controversial just on common sense grounds, but it would be just as big a political fight as fixing the health care financing system.

Posted by Meh | May 29, 2007 9:24 AM

Um, another reason that physicians prescribe statins is that they work and they are relatively inexpensive. So, let's not get all Jane Brody-ish about public health.

Posted by MattF | May 29, 2007 9:25 AM

Let's get real. If you go in a bookstore, you will find there's no shortage of information, plans, calendars, even whole-life philosophies (in addition to the 3000 years of religious injunctions) about health.

What we don't have are public policies that work, and the reason for that is simple- huge industries that lobby in Washington DC and every statehouse. Most of what they lobby for, to be fair, is stuff that might not be harmful to the person who has excellent health habits and enough money to maintain them.

A lot of us are not that hypothetical wise and cautious person, and at the end of the day we are offered a quick fix- drugs. This would be a bad thing if you were going to smoke a joint instead of drinking a cocktail, but it's often seen as a good thing as a substitute for sane and vigorous public policies.

Being thus, both privately and publicly, weak willed and lily livered, we'll probably dangle slowly in the wind until events come to our rescue.

Posted by serial catowner | May 29, 2007 9:53 AM

the person who has excellent health habits and enough money to maintain them. - serial catowner

That's the problem, though, isn't it? Money? Thanks to the glut of cheap calories (which, don't get me wrong, is a good thing -- I don't wanna go back to a time of constant starvation for all but the wealthy few, do y'all?), it's now easy for even the poorest in this country to get enough calories (and then some). What's difficult is for them to get enough healthy food (which is expensive), exercise, etc.

As people above have already mentioned, this all has been well documented and it's not too difficult (see, e.g. Pollan's ideas) to figure out what to do. The question is whether we'll see enough popular will to defeat special interests here.

Posted by DAS | May 29, 2007 10:00 AM

I think, philosophically, there's a big difference between providing universal health care to everyone, and improving people's average health.

I believe that it is more important to do the former than the latter. A healthy lifestyle is mostly an individual's decision, so I don't mind if the majority of individuals decide its not important to them, and end up dying early. It does bother me, however, if someone dies prematurely because of inadequate access to health care, through no choice of their own.

Another issue is, much of our happiness is due to our status relative to everyone around us. As a very healthy person, this is a source of happiness to me. If everyone else adopted a similarly healthy lifestyle, then in a relative sense that would set me back.

Posted by Jim W | May 29, 2007 10:05 AM

I don't mind if the majority of individuals decide its not important to them, and end up dying early. - Jim W

However, if you were paying for their health care, the health of other people would matter to you.

If universal health care existed here, maybe that would provide the incentive to make changes in farm policy, etc., to make healthy food cheaper and less healthy food less cheap? Or maybe, it'd work the other way -- as the tax based would just want people to die off quicker and more cheaply?

But the two very much are linked ...

Posted by DAS | May 29, 2007 10:26 AM

I do think its important that healthy foods are easily available to everyone, including poor people in the inner cities. And, I support simple measures like banning trans-fats in restaurants.

Obviously, farm policy is important insofar as it warps the cost of food, so we do want healthier food to be as inexpensive as possible, wrt unhealthy food. My larger point, however, is that it is a much worse situation when bad things happen to people through no choice of their own, than when its a result of their choices.

This is why I've never been enthusiastic about the anti-smoking campaigns. I figure, if people want to take those risks, why not let them?

Posted by Jim W | May 29, 2007 10:35 AM

It's pretty simple. We have a de facto national policy that is based on keeping hydrocarbons cheap, and subsidizes the transformation of them into carbohydrates.

Posted by vorkosigan1 | May 29, 2007 11:15 AM

I don't want to sound like a nerd, but I grew up in Oregon and we had 'health' class for a semester for four years of middle and high school. It was mostly 'eat healthy, get exercise, don't have unprotected sex, don't be anorexic' kind of stuff.

I don't know about kids growing up elsewhere, but if you didn't listen to it then, when are you going to listen it? After they saw your first leg off from diabetic neuropathy?

I agree with Ezra. Prevention sounds easy, but is much, much harder.

P.S. Having good parents helps. I'll bet that there's a reason that Scandinavia does well in all these studies.

Posted by Klug | May 29, 2007 11:17 AM

One such policy: promote ethanol as a way to divert surpluses of corn away from manufacture of cheap corn syrup. Michael Pollan convincingly argues that the overabundance of corn syrup (an effect of Nixon-era corn subsidies still in place) has much to do w/ the obesity crisis. (Just as bumper crops of corn in the late 19th C brought price-declines in corn liquor, and thus the alcoholism crisis which prompted Prohibition.)

Ethanol doesn't help environmentally (CO2 emissions are the same whether from biofuels or petrofuels), but corn-based ethanol wd make us less dependant on Middle East oil, AND it wd make corn syrup a more expensive flavor to add to foods.

Posted by helmling | May 29, 2007 12:18 PM

I don't want to sound like a nerd, but I grew up in Oregon and we had 'health' class for a semester for four years of middle and high school. It was mostly 'eat healthy, get exercise, don't have unprotected sex, don't be anorexic' kind of stuff.

This is the first time I've heard public school health class referred to in a favorable way. I remember it well and don't consider it to be a good model for future government expenditures.

Posted by JP | May 29, 2007 12:21 PM

"Smoking" seems like a pretty definitive one-word refutation of Ezra's point. Anti-smoking measures have changed people's behavior in a very dramatic and positive way. I think there's a rather large burden of proof on anyone who says other behaviors couldn't be changed similarly.

Just about all of them are really politically difficult to implement in the US. It's well known, for instance, that mandating healthy meals for children in schools and throwing out the vending machines has the potential to make a massive public health impact.

As a matter of fact, New Jersey just adopted a ban on soda, candy and junk food in schools. So obviously it's not that hard.

Posted by lemuel pitkin | May 29, 2007 12:37 PM

JP: I guess I didn't think on it favorably, but I did get the CW on such issues. It seems to me that the majority of preventative care-type scenarios are a extension of 'health' class. I don't think they're going to help much, either.

If you didn't listen then, why are you going to listen now?

Posted by Klug | May 29, 2007 1:40 PM

Re: but I think it's pretty easy to think of policy measures that would somewhat increase people's propensity to walk or ride a bike rather than drive their car.

For most people, neither walking nor biking to work is an option. You REALLY need to stop thinking about your own life and teh lives of your freidns and start looking at the reality of American life for most of us. For the vast majority of people, work is simply too far away to get there other than by motorized travel. So you could maybe with extreme (and much resented) effort, get them onto public transportation instead of cars, but of coyurse sitting on a train or bus provides no exercize benefit either. And even for people who may live close enough to ride or walk, other factors prevent them: safety, for example, or the desire (and need) to arrive at work clean and fresh smelling*, or then eed to run errands that require carrying passengers or cargo on the way to and from work.

* Two years ago, when I lived six miles from my job, and when we had but one car for two people, I had my partner, whose job was much farther away than mine, drop me off with my bike in the morning, and I did ride home. But I never even considered riding to work: it was way too dangerous to be on the roads during morning rush hour in the pre-dawn gloom and (often) fog; and I most definitely did not want to show up at my job beraggled and sweaty complete with "helmet hair"(I live in Florida; one works up a sweat here even in mid-winter) .

Re: These things -- a carbon tax, say -- would be politically difficult to achieve, but so would comprehensive reform of the American system of health care finance.

Healthcare reform is difficult because it goes against major vested interests-- but at least the American people would get something in return. A carbon tax is not going to fly because not only because special interests would lose out, but so too would the vast majority of ordinary people who would lose without gaining. On some issues, Matt, you coudl not be more out of touch with daily reality in this country if you lived on Pluto.

Re: However, if you were paying for their health care, the health of other people would matter to you.

Whether poeple live a long time or not their healthcare will cost money. Here's the bitter truth: unless you are "licky" enough to die of some sudden traumatic event, no matter how healthy a life you live, at the end you will end up frail, ill, and a very expensive person to care for. Maybe that will happen at 90 rather than at 70 for the health nuts out there, but it will still happen.

Posted by Jonf | May 29, 2007 1:42 PM

Its not that difficult to get soda and candy machines out of public schools . . . give the Principal money, and its done. What *is* difficult is paying for it (or more healthful lunches). Trans-fats are a cheap way to make processed food taste good for a long time. Using fresh food is more expensive. But its not really *difficult*. Making salads isn't rocket science, the problem is that in public schools there isn't funding for the lunchroom so they *have* to sell stuff at a profit and end up catering to the lowest common denominator. Converting public school cafeterias to whatever kind of system you want is simply a matter of funding. This isn't finding a political solution for Iraq or fusion in a jar.

So without any numbers, what would it cost to dramatically improve the quality of school lunches and what impact could we expect in terms of public health? And, of course, would this lead to healthier diets for adults? How much more of a bang for the buck would this give as compared to Universal Health Care? It seems to me that these are decent questions to consider.

Posted by William | May 29, 2007 4:46 PM