Academic journal article Missouri Law Review

Nudges for Health Policy: Effectiveness and Limitations

Academic journal article Missouri Law Review

Nudges for Health Policy: Effectiveness and Limitations

Article excerpt


The United States spends a far greater proportion of its income on healthcare than other high-income nations, but we get less benefit for our efforts. (1) The United States has poor health outcomes including the lowest life expectancy at birth, the highest rate of infant mortality, and much higher rates of obesity and other chronic diseases compared to our peer nations. (2) Our healthcare system is also typified by inequalities. (3) Health outcomes vary considerably by income as well as race and ethnicity. (4) And, at the end of 2015, our country had approximately twenty-eight and a half million uninsured non-elderly Americans. (5)

One tool that our government can use to combat these challenges is the use of health policy in the form of programs, regulations, and agencies that are aimed at improving the overall health and welfare of Americans. (6) Of the various approaches to shaping health policy, this paper will focus on the use of "nudges," a behavioral strategy for shaping human behavior from the framework, Libertarian Paternalism. In this Article, a nudge is defined as any aspect of choice architecture or any method of structuring the choice environment that influences behavior in a predictable way, with the restriction that this tool may not constrain or remove choices nor can it significantly increase the cost associated with any of the options. This definition is largely consistent with the original conception by Thaler and Sunstein. (7) This work was informed by the author's participation in the Behavioral Science & Policy Association working group on the application of insights from behavioral economics to health and healthcare. The working group produced a report, jointly commissioned by the Behavioral Science and Policy Association and the White House Social and Behavioral Sciences Team, that identified opportunities for federal-level behavioral policy interventions to improve the health and well-being of Americans. (8)


Before examining the evidence for the effectiveness of nudges in health policy, it is important to discuss the ways in which health policy differs from other policy domains. First, there are unique economic and political forces that shape the health policy landscape. (9) Second, health policy is aimed at addressing complex health behaviors that are rooted in American culture and are an integral part of societal interactions (e.g., eating, drinking, recreational drug use). (10) Changing these types of deeply entrenched behaviors requires health policies that are comprehensive and multidimensional. (11) Such an approach may include the coordinated implementation of traditional economic policies (e.g., taxes) alongside behaviorally informed strategies (e.g., nudges). (12) For example, a historical look at the rates of smoking in the United States reveals that smoking declined substantially with the combined dispensation of taxes, restrictions on advertising, and public smoking bans. (13) Thus, although nudges have had profound successes in other domains (e.g., automatic enrollment has increased the amount of retirement savings), it is unlikely that nudges in health policy will produce similar singular successes. (14)


In this section, I review research that provides examples of effective nudges in health-related domains. However, I want to clarify that the intent of this manuscript is not to advocate for nudges as the panacea for our country's systemic health issues. Rather, the vision is more simply that nudges will be one of several tools available in the health policy toolbox. In this Article, I do not provide an exhaustive review of the efficacy of nudges for all areas of health and health behavior. Rather, I summarize research from three areas where nudges have been successful in improving health or optimizing the healthcare system. …

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