Since 2003, the President's Emergency Plan for AIDS Relief, or PEPFAR for short, has been USAID's global health initiative to fight HIV/AIDS. PEPFAR has received over $100 billion in funds for the response to HIV/AIDS. It has been the largest global health program dedicated to fighting a single disease. Why is PEPFAR making it on my blog? Aside from PEPFAR services being disrupted by the Trump administration cancelling various foreign aid contracts (read study on preliminary effects of that disruption here), Congress extended PEPFAR's reauthorization last year. If the reauthorization is not renewed, it is set to expire tomorrow: March 25, 2025.
This begs the question of whether PEPFAR should be reauthorized or not. Some of you might expect a knee-jerk response of "No" from me simply because it is a sizable government program. Last month, I made an argument for shutting down the U.S. Agency for International Development (USAID) in no small part because of the perverse incentives that foreign aid generally creates. That much is true. Additionally, I worry about how much on PEPFAR is spent. In FY2024, the government spent $6.5 billion on PEPFAR. Although it is about 0.1 percent of government spending, I am quite concerned with the ballooning public debt of the U.S. government.
At the same time, the price tag and the fact that it is a government program are not prima facie adequate reasons for me to automatically say "No." I am first and foremost a consequentialist libertarian. What this means is that my main reason for being libertarian is because I find that freer markets, lower taxes, and fewer regulations generally create more desirable outcomes than government intervention.
It would not be the first time I argued for at least some government intervention in public health policy. I have done so by arguing for birth control subsidies, partial smoking bans, and paying people to take the COVID-19 vaccine, all of which I did from a libertarian lens. One of the reasons I have such problems with government intervention generally is because it does not solve the problem the policy was intended to address, or even worse, it exacerbates the problem. A government policy that actually helps is a notable exception, not a norm. Looking at the data, it looks like PEPFAR is one of those exceptions from an outcomes-based point of view.
PEPFAR's main success is its considerable positive health outcomes. PEPFAR reports that it has saved 21 million lives. The Kaiser Family Foundation found that PEPFAR reduced the all-cause mortality rate in recipient countries by 20 percent. I came across an independent citizen review of PEPFAR (Piper et al., 2024) that estimated that PEPFAR saved between 7.5 million and 30 million lives between 2004 and 2018. At that point, $70 billion was spent. That would mean PEPFAR costs between $1,500 and $10,000 per life saved.
Let's create a low-bound estimate for this cost-benefit analysis. Use the average life expectancy payout from life insurance in the U.S. (i.e., $168,000) and the low-bound estimate of 7.5 million lives saved. it would mean $1.26 trillion in benefit for lives saved for the $70 billion spent, or $18 of benefit for each dollar spent. If you use the value of life from FEMA or EPA of around $11 million along with the high-bound estimate of lives saved (i.e., 30 million), the benefit-to-cost ratio increases to over $4,700 in benefit for each dollar spent.
This back-of-the-envelope cost-benefit analysis is quite frankly astounding. And to think it does not even consider the benefit of greater economic stability. The Kaiser Foundation calculated that PEPFAR was associated with a 2.1 percentage point increase in GDP from 2004 to 2018. Even if the boost to GDP was only 1.4 percentage points (Tompsett, 2020), that would still mean a $14 increase in per capita income for the sub-Saharan region, which is significant for a region with lower purchasing power. An economic analysis in the Public Library of Science found similar boosts to the GDP and education outcomes (Crown et al., 2023). Why would it create better economic outcomes? Because people who are healthier and live longer are able to contribute to the economy.
One could argue that PEPFAR puts major emphasis on HIV/AIDS while de-emphasizing other health issues in those regions, such as malaria, tuberculosis, maternal health, or malnutrition. One could also argue that the U.S. government should focus on health problems at home, whether that is the opioid crisis or diabetes and heart attacks primarily caused by high obesity rates. Where funds should be spent and how much are subjective policy preferences directed by one's priorities and values.
I would counter by saying that HIV/AIDS is another example of how a public health problem can be global, much like we saw with the COVID pandemic. Rather than focusing on government-to-government aid, PEPFAR focuses on public-private collaboration with pharmaceutical companies and suppliers of diagnostic tools, treatments, and other health technology to strengthen the private-care healthcare systems of developing countries that have been contending with high HIV/AIDS rates. This means that PEPFAR strengthens local health systems in the long-run instead of creating dependency on foreign governments for treatments and preventative services.
Focusing on both HIV/AIDS treatment and prevention not only mean a lower mortality rate, but also means that stopping future infections means fewer dollars spent on treatment, especially if those dollars are spent by the government. Tangentially, the Right-leaning Center for Strategic and International Studies (CSIS) makes a case for using PEPFAR to strengthen global security for when the next disease strikes. PEPFAR is an example of what foreign aid should strive for, rather than most foreign aid that perpetuates dependency and malfunctioning economies and political institutions.
Does that mean that the PEPFAR program is perfect? No. Even someone as critical of PEPFAR as the Right-leaning Heritage does not suggest eliminating PEPFAR, but rather reforming PEPFAR. If USAID is indeed eliminated, PEPFAR could be managed solely by the Centers for Disease Control and Prevention (CDC) or the Department of State instead of having USAID participation. There can also be better programmatic objectives, a focus on more countries due to the global nature of the HIV/AIDS epidemic, or even figure out how PEPFAR could develop sustainable health systems that can address multiple diseases.
Much like I did with arguing for birth control subsidies, the libertarian in me has to ask what sort of costs would be incurred if the program disappeared versus the cost of the program itself. Some problems that would emerge by eliminating PEPFAR include increased HIV transmission and new infections, rising mortality rates, increased healthcare costs, economic stability and social unrest, and potentially regional instability in parts of the world that already have more than their fair share of issues. The interconnectedness of these problems could create problems not only on a regional level, but a global one.
Some might balk at the price tag, but I would contend that it would cause more problems in the big picture by removing PEPFAR. I will conclude by saying that even with a need for reform, the number of lives saved and economic benefit derived from PEPFAR, not to mention the problems and headache avoided, make a very strong case for PEPFAR.
While I appreciate the thoughtful analysis and cost-benefit breakdown, calling this position “libertarian” stretches the definition to the point of distortion. At best, this is a pragmatic argument for selective government intervention based on perceived utility — which might make you a utilitarian centrist, but not a libertarian in any meaningful sense of the word.
ReplyDelete1. Libertarianism isn’t utilitarianism with better outcomes
Libertarianism — consequentialist or deontological — rests on first principles of limited government, voluntary exchange, and non-aggression. A program like PEPFAR, no matter how well-intentioned or efficient, involves:
• Taxation (i.e., coerced redistribution),
• Foreign aid (i.e., non-domestic spending without consent), and
• Government-led intervention abroad (i.e., mission creep and entanglement).
These are precisely the kind of things libertarians have historically opposed — not because they hate outcomes, but because the mechanism violates the foundational principle of individual liberty.
2. “It works” isn’t a libertarian test
By that logic, we could justify all kinds of government programs — Social Security, Medicare, food stamps — simply because they improve outcomes for some segment of society. That’s a welfare-state mindset, not a libertarian one. The bar for government action under libertarianism is much higher: it must either protect individual rights directly or be strictly limited to public goods in the narrowest classical sense (defense, courts, basic rule of law).
3. Foreign aid is the antithesis of libertarianism
PEPFAR is foreign aid. Even if it’s delivered via public-private partnerships, the funding and direction are ultimately rooted in federal bureaucracy. Libertarians have long viewed foreign aid as government overreach, rife with inefficiencies, perverse incentives, and unintended consequences. That hasn’t changed.
4. You’re importing progressive moral logic
The argument that “saving lives abroad is worth it, especially at a good cost-benefit ratio” relies on moral collectivism and global utilitarianism — not individual liberty or voluntary association. A true libertarian would argue that if Americans want to support HIV/AIDS relief abroad, they should do it through private charity, not forced taxation.
5. Consequentialist ≠ consequentialist libertarian
Calling oneself a “consequentialist libertarian” doesn’t mean every good outcome justifies a breach of principle. It means one believes liberty tends to produce better outcomes — not that liberty can be set aside whenever a government program happens to pass a spreadsheet test.
You’ve made a compelling pragmatic argument for continuing PEPFAR. But to call it a libertarian argument is intellectually dishonest or at least semantically misleading. It’s a consequentialist case for a benevolent, outcome-efficient government program — which is fine, but it’s not libertarianism. If everything that “works” justifies government action, you’ve left libertarianism behind and entered technocratic liberalism.
And that’s okay — just don’t redefine the label to make the contradiction more comfortable.
First and foremost, I appreciate both the thorough response and the compliment on providing a compelling pragmatic case for PEPFAR. It gave me the chance to critically review what I initially wrote. Part of why I labeled it a “libertarian case” is because my argument goes out of what is considered normative libertarian argumentation, as you point out in your reply. Yes, I argue in an atypical/out-of-the-box fashion, but it is far from being a distortion of libertarianism.
DeleteYou made a comment about taxation being coerced redistribution, but then you acknowledge that it could be “limited to public goods in the narrowest classical sense.” By pointing out defense, courts, and rule of law as exceptions, you acknowledged concessions that require taxation, which only an anarcho-capitalist would construe as a prima facie violation of individual liberty. Here we are reminded that libertarianism, like other political philosophies, exists on a spectrum.
My libertarianism doesn’t exist in a vacuum—it contends with the world in which we live. Aside for blogging here for over 15 years as a libertarian, any time I have taken a political spectrum test in the past 15 years, I have always scored as a libertarian. I will say that those who know me well enough were amused to know that I was called a utilitarian centrist for the first time in my life, but I digress.
If there were some viable way to successfully implement a strictly free-market option with zero government in this instance (e.g., having Bill Gates donate billions to HIV/AIDS relief) that would have zero impact on individual liberties, that would be great. However, the world doesn’t work that way. I believe in a libertarianism that can be applied to real-world problems instead of one that only serves to fulfill an ideological purity test. The pragmatist in me says that you need to go for the best option (or in some cases, the least worst option) that can be implemented in the real world because you do not want to make perfect the enemy of good, no matter how ideologically tempting it might be to do otherwise to rigidly adhere to principles.
DeleteTo reinforce the idea of libertarian values existing on a spectrum, here are a couple of examples: NAFTA was not a purely free-market option provided by private-sector actors. It was a free-trade agreement created by nation-states with a number of trade restrictions. Even so, NAFTA made trade freer than it was beforehand, increased voluntary exchange, and improved the quality of life for millions. The Grameen Bank in Bangladesh exists by the authority of public statute. However, the Bank leveraged voluntary exchange and market-driven development vis-à-vis micro-finance while pulling enough Bangladeshis out of poverty that it won a Nobel Prize. Although both examples entailed government action, they were both improvements over the status quo that resulted in greater abundance of values that libertarians hold dear. I consider those wins from a libertarian lens.
My take on PEPFAR is in a similar vein. You cannot isolate the consequentialist portion of the argument because it has bearing on a libertarian response. I think even you believe so because otherwise, you would not have mentioned that libertarian opposition to foreign aid is based on foreign aid being “rife with inefficiencies, perverse incentives, and unintended consequences.” I generally agree with that assessment, especially in light of the fact that I blogged in favor of eliminating USAID a few weeks ago. That assessment of foreign aid has something to do with the fact that foreign aid primarily is government-to-government aid that props up authoritarian regimes, thereby hindering the proliferation of a market-based economy.
PEPFAR does not work like standard foreign aid for a number of reasons. Yes, PEPFAR is a government program, but it is a relatively targeted and narrow one, thereby adhering to the principle of minimal intervention (i.e., limited government). That is not leaving libertarianism behind, as you put it. PEPFAR also has increased voluntary exchange in developing countries (which is a feature of having freer markets) and has leveraged private partnerships in these health markets (e..g, medical suppliers, local health organizations), both of which minimize government overreach.
DeleteIts enormous success in terms of health benefits helps prevent global health crises, a success large enough for you to have acknowledged. That success, in turn, increases economic & social stability (thereby reducing long-term government spending; more on that momentarily), and mitigates destabilizing forces in markets, both of which create more favorable conditions for a market-based economy. For me, it is more important to see greater liberty in practice than theoretical pontification about ideals, even if it comes in a different form than we would like.
As both a libertarian and pragmatist, the question I ask myself is not about “is there government or no government.” If the world operated on that simplistic binary to the point where that was the only factor in play, I would agree with you that advocating for PEPFAR would not fall within the realm of libertarianism. But the world operates differently.
Rather, as a libertarian, I ask the question of “which option results in the least amount of government intervention” because what I understand is that there is no politically feasible option in this scenario that leads to zero government intervention. What worries me is what would happen in the absence of PEPFAR versus having PEPFAR.
DeleteRemoving PEPFAR would most likely lead to more destabilized economies and greater social unrest. That greater instability would result in more government intervention than in comparison to PEPFAR, whether in terms of higher health care and welfare costs bore by the recipient countries, economic bailouts, greater authoritarian measures to quell the social unrest, or quite possibly having the U.S. intervene militarily if the situation truly deteriorated.
The history of the countries served by PEPFAR indicates that these scenarios entailing greater government intervention are well within the realm of reasonable plausibility and in fact point in the direction of the most likely outcome. If the choices are between a minimal government intervention versus having the erasure of said minimal intervention result in greater government intervention, I would choose the former any day. Why? I don’t know about you, but I would rather have a world with less government intervention than more. In this instance, I am opting for the least worst option here/the lesser of two evils while remaining within the realm of libertarian thought.
Consequentialist libertarianism is not about blind opposition to all government action. As libertarians, we should be asking ourselves which policies expand freedom and minimize government coercion in the grand scheme of things. I prefer an improvement of the status quo over chasing after a utopia. The fact that PEPFAR is demonstrably effective, uses such libertarian principles as limited government and increasing voluntary exchange with private-sector actors, and prevents greater government overreach all add up to a libertarian argument in favor of PEPFAR.
Advocating for PEPFAR is not an abandonment of libertarian principles. It is the pragmatic and practical application of these principles in a complex and imperfect world.
Thanks for the thoughtful and well-argued response. I’ve been reading your blog for over a dozen years and have always respected your clarity and consistency — even if I did get a laugh out of calling you a “utilitarian centrist” for the first time.
ReplyDeleteThat said, I still maintain that support for PEPFAR, while perhaps defensible on pragmatic grounds, falls outside the bounds of libertarianism. It’s funded through taxation, involves redistribution without individual consent, and operates internationally — all red flags from a libertarian perspective.
Your case is compelling: PEPFAR is targeted, efficient, and avoids the worst forms of government-to-government aid. But those features make it less bad, not libertarian. Saying it prevents greater government intervention down the line may be true, but that’s a realist justification, not a principled libertarian one.
You’re not abandoning liberty — you’re suspending it for what you view as the lesser evil. That’s fine. Sometimes pragmatism wins. But let’s not pretend it’s libertarianism. It’s a smart policy case,just not a libertarian one. And that distinction matters.
I also appreciate your thoughtful response, as I do over a decade of your readership. I must say that I’m enjoying this discussion. It is obvious we both want greater freedom and less government intervention. Where there is still a point of contention is in what constitutes as “libertarian policy.” Your assumption is that if a policy does not check off all the criteria on a list, it is not actually libertarian. I am assessing whether something is libertarian based on a spectrum. Would I like a policy situation that checks off all the boxes? Yes, that would be the ideal situation. What made this blog entry especially challenging for me to write was grappling with what do I conclude based on being faced with a suboptimal situation in which you cannot get everything you want policy-wise.
DeleteMuch like with the NAFTA and the Grameen Bank examples I provided, they did not check off all the boxes I would ideally like to have checked off. But they checked off more boxes than their previous status quo or their alternatives. I would like to see a NAFTA alternative with fewer trade restrictions, but I know that’s unlikely with President Trump having announced reciprocal tariffs today. Another example: school choice. In an ideal libertarian world, public education would not exist. However, Milton Friedman advocated for school choice as a next-best option to give people greater choice. It did not make him less libertarian, but it was him contending with a real-world issue the best he could.
I don’t think it is prudent to dismiss this sort of pragmatism as “insufficiently libertarian.” A criticism of libertarianism that has been lobbed at me over the years is that libertarianism is not practical or applicable in the real world. A more libertarian world does not take place by theorizing or looking at it through an academic lens. It is how one is to implement these ideas in practice and towards real-world scenarios. If we ignore realities about economics, politics, institutions, and human nature, libertarianism ceases to be irrelevant and I don’t want that.
DeleteHaving been both an economics professor and a politician, this is something I imagine Argentinean President Javier Milei has learned to appreciate since he became President. He ideally would like to have little to no government intervention in Argentina. However, he has to face the reality of major political opposition along with other considerable obstacles. He has not dollarized or removed capital controls as I would like to see. He also raised the PAIS tax [a tax on purchasing dollars], income tax, and fuel tax, which would be problematic from a strictly libertarian lens. But I can also appreciate what he has done to advance libertarian values on the whole. I realize that his presidency is not an all-or-nothing, either/or assessment, much like with what we have been discussing about PEPFAR.
Aside from the limited government and supporting market-based solution components of PEPFAR, the libertarian argument that resonates with me the most is that removing PEPFAR would mean greater government overreach. PEPFAR being a government program does not help it check off all of the boxes on that list of criteria for “ideal libertarian policy,” as you amply illustrated. However, a government program paradoxically ends up being the least worst option/most libertarian option in this scenario. Libertarianism is best achieved in practice when balancing principles with real-world application. I would like to see freer markets, greater liberty, and less government intervention throughout the world, and pragmatism is the best way to see those ideals become more of a reality.
Just realized a typo that I can't go in and edit because of the limited functionality on this blogging platform, but I meant to say "ceases to be relevant."
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