Injecting public choice into public health: the political economy of public health

Public health theorizes human behavior through three dominant models—the Health Belief Model, the Theory of Planned Behavior, and the Transtheoretical Model—each resting on assumptions about how individuals decide, what motivates public health officials, and how communities solve collective problems. Public choice economics rests on different assumptions about exactly these questions. Yet, no one has explicitly compared these seemingly confrontational assumptions, and that confrontation, rather than another synthesis of what public choice has said about health policy, is this article’s object. We compare the three public health models assumption by assumption along public choice’s three foundational precepts—methodological individualism, motivational symmetry, and collective action—and consider where they generate competing predictions about health behavior and policy. Adjudicating against the most demanding recent case, the COVID-19 pandemic, we find that the public health models systematically treat individuals as targets of intervention and officials as benevolent—assumptions public choice rejects and that the pandemic repeatedly falsified. Incorporating public choice and the expanded role for self-governance offers public health a more accurate account of why people and the policy makers who govern them behave as they do.