Citizenship as a Form of Anticipatory Obedience? Implications of Preventive Health Policy in Germany

This article scrutinizes citizenship implications in the field of preventive health policy in Germany. While at first glance prevention policies seem fairly uncontroversial, they have intricate links concerning the impact on preventive policies to social citizenship and to the notion of the “good” citizen. I argue that prevention is a future- oriented permanent task that requires constant alertness and the commitment of responsible citizens to being “ahead of time.” Although originally based on the principles of voluntary compliance and self- responsibility in Germany, preventive policies are likely to become more compulsory in the aftermath of the COVID- 19 pandemic that has, in effect, been a collective crash course on the importance of prevention and its range of policy tools. Under the prevention paradigm, active citizenship requires anticipatory action— that may turn into obedience— due to the imminent danger of assumed health risks.

interventions to impede potential social ills-crime, deprivation, disease, poverty, unemployment, and the like-in the future. As I show here, prevention policies address a specific type of good citizen that deviates from previous role models. In order to be prepared for major societal challenges such as climate change, digitalization, or the spread of noncommunicable diseases (NCDs), good citizens ought to think and act "ahead of time" and in compliance with government prevention policies. Thereby, governments support citizens in different ways to become "future-proof:" by informing them about evolving risks, sanctioning grossly negligent behavior, investing in citizens' skills and capabilities to cope and manage risks, and also by changing citizens' life-worlds and social environments. Notwithstanding which (combination of) approaches are pursued, government action has implications for citizens' rights and obligations. In line with the central concept guiding this Special Issue, prevention policies are either explicitly, or implicitly "designed in order to convey civic norms" (Barrault-Stella and Douniès 2019). The overall purpose of prevention, requiring citizens' sustained compliance is, thus, not questioned. Who dares to doubt the necessity of active lifestyles or a balanced diet? This article scrutinizes which kind of good citizen policy makers have in mind when intervening in people's lives to prevent imminent health threats. To that end, a general theoretical analysis is provided that examines the relationship between the concepts of (social and public) policy, citizenship, and prevention. The goal of prevention allows policy makers to recalibrate social citizenship, conceived as the interplay of civil (e.g., protection from harm), political (e.g., participation in decision making), and social (e.g., welfare entitlements) rights (Marshall 1950). By relocating the reference point of policy to an uncertain and potentially dangerous future, prevention policies urge-but usually do not coerce-citizens to adapt themselves to a reasonable behavior in the "here and now." While in recent years the prevention paradigm gained importance in the light of the rise of NCDs and policy interventions informed by behavioral research (Lourenço et al. 2016;OECD 2017), it is the COVID-19 pandemic that has ultimately pushed the issue on top of policy makers' agendas. Prevention has become the reference point of health policy (and beyond) and is likely to have a lasting impact on policy making and the way policy makers will address citizens in the upcoming years. I argue here that this paradigmatic shift may result in a further "politicisation of behavior" (Peeters 2013, 357) by policy makers who take a judgmental view on citizens' health-related lifestyles. It may also reinforce the responsibilization of policy targets as it has been the case in other policy fields (Dent 2006;Ilcan and Basok 2004;Lister 2011). Despite the immense and immediate impact of the COVID-19 crisis, the shift toward prevention has to be assessed more generally in relation to health policy contexts and its implications for the meaning of health citizenship (Ewert 2019a).
Taking the example of disease prevention and health promotion in Germany, this study scrutinizes citizenship implications. Germany traditionally pursued a soft approach with regard to prevention based on public campaigns and health education. However, government and health insurances increasingly use preventive rhetoric and some tentative actions to address health-conscious citizens. In view of impending risks such as multimorbidity due to (preventable) chronic diseases, citizens should keep to the precautionary principle. The ad hoc implemented COVID-19 measures could have been the harbinger of a more resolute "preventive gaze" (Peeters 2013) by German state agencies and health policy makers in the future.
The article's line of argumentation unfolds in four parts. The first part establishes the theoretical framework sketching out the interrelations between citizenship, social policy, and prevention. Major strands of citizenship theory, its normative assumptions, and ways how public policy can stimulate good citizenship are recapitulated, followed by a brief review of Marshall's (1950) path-breaking concept of social citizenship and its implications for social policy. On that basis, prevention policies are theoretically scrutinized from a citizenship perspective. Theoretical insights are applied to the field of preventive health policy in Germany and recent developments during the COVID-19 pandemic. Citizenship implications emanating from German prevention policies are then discussed by referring to the notion of the good citizen. Finally, key findings are briefly summarized in the conclusion.

Good Citizens and the Concept of Social Citizenship
Reflecting on citizens' rights and relations to public policy is a privilege of democratic societies. It presumes not only that citizen inputs are a relevant factor in the policy-making process, but that there are different ideas and concepts available to design state-citizens interactions and citizenship through public policy (Schneider and Ingram 2004). In contrast, in authoritarian regimes, citizens are mere subjects whose obedience is taken for granted or, if necessary, enforced by compulsion. In this section, notions of the good citizen in public policy making will be revisited first. Second, Marshall's (1950) concept of social citizenship will be recapitulated to clarify the citizen's relation to social policy.

Being a Good Citizen and the Impact of Public Policy
According to Schneider and Ingram (2004, 329) "almost every public policy impinges on citizenship in ways either large or small, positive or negative." Citizenship traditions are, thus, repeatedly mixed and reassembled within policy sectors. For example, German statutory health insurance (SHI), representing in republican tradition a classic compromise between those in power and collective citizens, could be perceived from a liberal tradition as state intervention in private affairs. Liberals may, therefore, opt for more individual freedom: for example, private health insurance markets or, at least, opportunities for citizens to individualize SHI provision through tailor-made tariffs and selectable insurance options (add-ons). Communitarians, in contrast, may have an interest that large-scale health insurance schemes entail a sense of community and civicness as expressed in personalized care arrangements offered by local providers (Evers 2010).
Viewed this way, public policy making entails a constant stream of communication with citizens specifying what kind of citizen behavior and civic virtues policy makers want to see. Vice versa, in democratic societies citizens could influence the manner where they are addressed by sending messages to policy makers concerning the design and the content of policies. This is exactly where the debate on co-production in public administration locates untapped potential for good citizenship (Durose and Richardson 2015). Generally, images of the citizen and citizenship behavior are not coherent; they vary across policy fields and with regard to target groups. Pluralist societies are challenged by complex policy problems and, therefore, require different contributions by different kinds of "good" citizens. For example, migrants and newcomers are expected to learn the language and accept the values of the arrival country, while there are no particular claims toward native citizens with regard to integration policies. Similarly, in social policy chronically ill and unemployed citizens are addressed differently to healthy employees, even if both target groups enjoy the same citizenship rights and social entitlements. Hence, as a matter of fact, "[t]here is nothing neutral about the relationship between public policy and democratic citizenship" (Schneider and Ingram 2004, 329). In short, the talk of the good citizen who serves as a role model and is compliant toward public policy goals always implies the existence of its counterpart: the not-so-good citizen whose resistant or deviant behavior is a thorn in the eye of the policy maker.
To further unpack the notion of the good citizen in public policy, Pykett, Saward, and Schaefer's (2010) distinction between citizenship as an act and as a status is illuminating. While the latter is almost automatically associated with welfare provision-see the next section on Marshall's concept of social citizenship-the former refers to the actual behavior of citizens that is invoked by public policy makers. In line with citizenship as an act, "the idea of the good citizen is primarily about what citizens do, or what they should (or sometimes are forced to) do" (Pykett, Saward, and Schaefer 2010, 527). As argued, prevention policies, regardless of whether they are launched from the left or the right, seek to mold citizenship acts based on assumptions with regard to future risks that should be avoided. The second argument by Pykett, Saward, and Schaefer (2010, 523) is important too: good citizens, defined by accumulated citizenship acts, are "framed in the sense of viewed from a certain perspective, and in the different sense of set up for a particular purpose." Accordingly, good citizens are a social construction that "are made in, and by, the image of key actors whose acts constitute operative ideas of good citizenship" (Pykett, Saward, and Schaefer 2010, 532). Simply put, the notion of the good citizen does not exist until it is created by policy makers. However, depending on who is in power and with regard to different policy issues, the political framing of good citizens varies enormously. For example, in the field of health promotion and disease prevention, policy makers address different notions of the active citizen who is either primary concerned with his/her individual health or may seek, together with other citizens, to improve the social structures that determine individual health (Ewert and Loer 2019). In each case, the framing of the good citizen takes place by the strategic positioning of arguments, motives, and methods (Pykett, Saward, and Schaefer 2010, 528) that make certain citizenship acts appear reasonable and others not.
In addition, on a more practical level, invoking notions of good citizenship requires utilizing "subtle messages of policy design" (Ingram and Schneider 1993, 68). This refers to what Howlett (2018, 103) coined as "matching of tools and target behaviour right at the outset of policy-making." It requires policy makers to strategically select (combinations of) policy instruments to stimulate certain citizen behaviors. This rather banal, but often overlooked, fact has gained new attention by the recent "behavioural turn in public policy" (Bogliacino, Codagnone, and Veltri 2016, 323) caused by Thaler and Sunstein's (2008) bestseller Nudge. Despite Schneider and Ingram's (1993, 334) seminal work concerning the "social construction of target populations" and its relation to policy design, there is still a significant need for research in this area. Evidence-based knowledge on citizens' actual behavior (i.e., who exactly should be reached?) and the behavioral effects of policy tools (i.e., do policy tools and target groups fit together?) is still limited. Policy makers have to deploy "a range of tools addressing and utilising different kinds of motivations" (Howlett 2018, 116) to actually invoke target groups' behavior. So far, due to poor policy design, intended citizenship acts are often performed by those citizens who, in the eyes of the policy makers, are compliant (or "good") anyway, while hard-to-reach persons (or "not so good citizens") often do not respond in the desired way. Often prevention policies, being one-sidedly directed to individual behavior change, but neglecting the social embeddedness of behaviors, fit this category (Baum and Fisher 2014). While the coupling of policy instruments and target groups is essential for the analysis of behavioral implications, the policy design literature does not further qualify the notion of the citizen but speaks rather generally about "policy targets." After sketching the links between good citizens and public policy, the next section recapitulates the status of citizens in the field of social (and health) policy. As I show, the meaning of social rights and duties may change due to the prevention rationale. Marshall's (1950) concept of social citizenship is a recurrent reference point in social policy analysis (see e.g., Crouch, Eder, and Tambini 2001;Evers and Guillemard 2012b;Lister 2005). For the purpose of this article, it is impossible to immerse into the richness and diversity of this research in full detail. However, by briefly reviewing the triad of civil, political, and social rights that, together, build the cornerstones of Marshall's citizenship concept, the groundwork is laid to properly assess the implications of preventive health policy.

Marshall's Concept of Social Citizenship
The bare bones of Marshall's citizenship concept consist of civil, political, and social rights that have been developed consecutively and mutually reinforce each other. Civil rights are deemed to protect the citizen from an intrusive and authoritarian state. Hence, the fragile situation of citizens in the face of powerful state bureaucracies is recognized by guaranteeing them shelter and the private sphere. Without this bedrock of citizenship, people's personal integrity would be under permanent threat. In addition, the granting of political rights gives citizens a say in state governance; that is, to associate, assemble, participate, and, most importantly, vote. Political rights, irrespectively of whether they are exercised by citizens or not, are core features of democracies and, hence, are most often used synonymously with the concept of citizenship. Although, according to Marshall, the latter is constituted by a third component; that is, a defined set of social rights such as benefits, entitlements, and services that are provided by the welfare state. Social rights are thought to have a compensatory effect: within capitalist societies, they strengthen the citizen's position in relation to unregulated markets in a similar way that civil rights strengthen the citizen's position in relation to unregulated state power. To what extent civil, political, and social rights are established, empirically realized, and interrelated with each other, strongly depends on a country's historical developments and welfare policy legacies. Following Esping-Andersen's (1990) somewhat simplistic distinction of "three worlds of welfare capitalism,"-that is, liberal, conservative-corporatist, and social-democratic-different citizenship regimes could be distinguished. Notwithstanding this, the respective mix of rights "citizenship implied a vision of what each inhabitant of a society could become, an image for societies and their citizens to strive for" (Johansson and Hvinden 2012, 42). Within the "healthcare state" (Moran 1999) the concept of health citizenship (Huisman and Oosterhuis 2014) developed over time and has constantly readjusted in terms of state-citizen relations (Ewert 2019a).
Scholars have challenged Marshall's (1950) concept of social citizenship, drawn up for the British society in the early 1950s, from various angles. Most significantly, it has been pointed out that the "traditional concept" needs to be revised in the light of "new realities" (Evers and Guillemard 2012a, 7) such as changing labor markets and more pluralistic societies. In this context, the balance between citizenship rights and duties on the one hand, and a passive and more active notion of citizenship on the other, has become crucial for a debate that revolves around the question of which obligations should be linked to the citizenship status. Marshall (1950) tended to emphasize rights stronger than duties that were either formalized (e.g., to pay taxes) or vaguely defined (e.g., to take interest in political affairs). His concept does not include a thick notion of agency; that is, "something exercised by citizens, and not simply a set of rights and duties" (Johansson and Hvinden 2012, 47). Rather than being an "act" (Pykett, Saward, and Schaefer 2010), according to Marshall citizenship has been, first of all, a formal status to be granted to privileged members of society (i.e., mostly male employees). Modern welfare states embrace "proactive and preventive 'investments'" (Jenson 2012, 67) into the development of human beings, therefore, they are inconsistent with a citizenship-as-a-status approach. To be effective, social investments seek to change citizens' attitudes and activate their capabilities to become agents in their own interests. From a social investment perspective, prevention and behavior change are key policy rationales of contemporary social policies. As Jenson (2012, 67) stated, social investments follow "an orientation to the future;" thus, prevention is deeply in line with the rationale of social investment by "taking action to generate some anticipated larger good" (Taylor-Gooby 2013, 56).

Prevention as a Recurrent Objective of Social Policy
For policy makers, the quest for prevention seems irresistible since prevention is better than cure (Billis 1981;Freeman 1999). Hence, there is literally no way to reject the idea to prevent social ills. In contrast, the famous dictum according to which "there is no glory in prevention" refers to the paradox that successful prevention policies might result in a situation where citizens believe that the government's preventative action has been unnecessary and exaggerated. These opposite assessments make it clear that prevention is contested by definition. More strongly than others, prevention policies are furnished with a moral compass. As Billis (1981, 371) noted, in welfare, prevention "usually means taking action which is judged socially desirable in its own right" and entails a clear-cut normative conviction: "we prevent what is 'bad' in order to promote what is 'good'" (Freeman 1992, 45). Thus, for the sake of prevention, policy makers have to make an active choice-based on a judgment about the present-between conceivable future scenarios. As a result, they seek to control the uncertainty of the future by making positive and negative predictions. For example, political leaders across the world responded very differently-and partly negligently-to the outbreak of the COVID-19 pandemic based on different assessments of how hard their country will be affected by the virus.
Despite a shared consensus among most policy makers that preventive policies are a "good thing," forms and substance of prevention policies vary widely due to different world views, social norms, and moral convictions. As exemplified by referring to the case of health policy in Germany (see the next section), prevention policies may identify very different causes of disease and illness. According to Freeman (1992, 47) "it is essential to preventive policymaking that it be vague." Theoretically, this vagueness legitimates policy makers to apply an open-end set of interventions on the behalf of prevention. A common distinction is to differentiate between primary or upstream prevention (i.e., to prevent harm before it occurs), secondary or midstream prevention (i.e., to mitigate the effects of harm), and tertiary or downstream prevention (i.e., to cope with consequences of harm) (Gough 2013b, 3). In general, most preventive policies favor forms of secondary prevention that reach from information campaigns and citizen education to early interventions such as the No Child Left Behind Act in the United States in 2001. As a prerequisite, effective prevention depends on the power to shape society by having a formal mandate or position. While governments and state agencies may launch prevention programs, other stakeholders (e.g., welfare associations, NGOs, and citizen initiatives) are normally not in a position to decide over and implement preventive policies. Thus, "doing prevention" on a large scale is the privilege of elites such as governments and street-level bureaucrats (Gale et al. 2017). Moreover, prevention is "by no means intrinsically 'progressive'" (Gough 2013b, 4). In most cases, prevention means to preserve a status quothat is, preventing things from getting worse-in the face of imminent risks. Referring to social policy, this means that entitled citizens in their various roles as patients, workers, and future pensioners are called to take preventive action to maintain a current status; that is, their state of health, income, or pension level. Thus, prevention does not empower citizens as "change agents" that challenge the structures and traditions of welfare systems. Instead, citizens should adopt themselves toward a predefined notion of prevention in view of an uncertain future.
Despite their empirical variance, preventive policies share at least three basic foundations: scientific understandings of cause and effect; the possibility of prediction; and the "capacity for controlled government intervention in social life" (Gough 2013a, 309). Each of these foundations could result in different forms of action that depend on ideological beliefs and political goals. Taking the example of obesity, it makes a difference whether policy makers detect individual lifestyles or the food industry as the key leverage for prevention. In addition, interventions could be placed on a continuum ranging from top-down behavioral regulations to participatory approaches that encourage people to improve health-related factors within their living environment. Regardless of its form, prevention is legitimized by insights that (social) risks are manageable and that, with the help of interventions in the present, citizens may live a "better" life in the future. Thus, "[p]reventive interventions are essentially acts of social engineering" (Freeman 1999, 234) that impact the notion of the good citizen and social citizenship by "sending out important messages about right behaviour" (239). In other words, preventers draft and design their own version of a future that is worth living. Based on these projections, citizens become informed about the assumed implications of imagined future scenarios, educated through behavioral change programs or regulated by prevention laws. Despite their various ideological underpinnings and contested practical designs, most prevention policies seek to increase citizens' compliance as Freeman (1992, 45) observed: "One of the key functions of a policy of prevention, then, is to reproduce the willingness of individuals, firstly to collude in the ideological reconstruction of social problems as individual problems and then, second, to cooperate as individuals in prescribed solutions to those problems." Hence, there are two citizen-related goals of prevention policies: In addition to citizens' behavior preventive action seeks to change citizens' consciousness and mindsets. Ideally, citizens reflect and internalize their government's future prognosis, accept their individual responsibility, and voluntarily turn into policy makers' accomplices. Taking into account that "preventive policy appears selfpropelling, constantly in need of renewal" (Freeman 1999, 239), citizens are called to perceive prevention as their very own project. Since ultimate objectives of prevention policies are undefinable-more prevention is always possibleprevention becomes a permanent task of active citizenship.
To sum up, "prevention is a political construct" (Freeman 1992, 48) that is used by policy makers to shape the meaning of citizenship and people's behavior in contemporary societies that are marked by uncertainty and multiple risks. In the next section, the relation between policy, citizenship, and prevention is exemplified by referring to preventive health policy in Germany.

Preventive Health Policy in Germany
The theoretical insights developed above will now be applied to preventive health policy in Germany. In terms of methodology, a dense case description of the policy field's institutional setting and the addressing of citizens will be provided. The latter is supplemented by an empirical snapshot shedding light on preventive action during the COVID-19 crisis and implications for future state-citizens relations. Analyzing preventive health policies in Germany through a citizenship lens seems justified for at least two reasons. First, it is interesting to reveal whether, and if so, how the prevention paradigm has been adopted by a political system that for a long time was marked by reluctance toward preventive policy interventions because of the country's Nazi past. Second, the citizenship implications of preventive policies are assumed to be more severe in Germany since the German health system puts citizens in a strong position not only with regard to entitlements, but also in terms of choice and voice in service provision (Köppe, Ewert, and Blank 2016).
Until very recently, disease prevention and health promotion have been rather marginal issues in the German health system despite frequent assertions by governments and policy makers to the contrary. The German SHI 1 system mainly focuses on health-care provision covering medical services and benefits, in kind, in the case of illness. Citizens' SHI entitlements are per definition unconditional; that is, not linked to certain health statuses or health behaviors. Moreover, citizens enjoy free choice of SHIs and health-care providers and opportunities to collectively voice concerns within the SHI system (Köppe, Ewert, and Blank 2016). Prevention policies are embedded within, and implemented by, the SHI system (Loer 2016). Hence, preventive services are provided on a regular basis by physicians and carers in outpatient and hospital care but also in cooperation with nonmedical partners, such as employers, schools, and kindergarten. In 2018, SHIs spent €554 million for preventive health services in fields such as nutrition, physical exercise, and stress reduction; however, the sum is merely a very small fraction (.24 percent) of SHIs' total budget (€226.2 billion in 2019). In addition to SHIs, the public authorities of the Public Health Service (ÖGD), including, among others, the Robert Koch Institute, the Paul Ehrlich Institute, and the Federal Centre for Health Education (BzGA), as well as state and local health authorities coordinate preventive action in crises and support public prevention campaigns.
German health policy largely frames prevention as an individual "doabilty" (Kickbusch 2009) to which good citizens become encouraged by SHIs and state authorities. Generally, prevention policies are not enforced by regulation but publicly promoted by policy stakeholders that seek to educate and empower health-conscious citizens. This overall tentative strategy toward prevention underpins the strong orientation of the German health system toward cure and health care despite looming challenges such as "the rising tide of noncommunicable diseases" (Budewig 2018, 392). Preventive measures pursued by the federal government range from a campaign called "Germany in search of the vaccination certificate" (to raise vaccination rates), the "IN-FORM initiative" (to improve people's eating and exercise behavior), annual organ donation campaigns (to remind people to save the lives of others), and to a health promotion screensaver freely downloadable at the Ministry's website (to promote prevention training for office workers). Common features of these policy tools are personalization (e.g., "Paul's desktop exercises…"), the use of celebrities as role models, and the normalization of prevention to be perceived as a self-evident matter of course (i.e., something that good citizens do).
Moreover, German policy makers cautiously employ behavioral (i.e., nudgelike) interventions for disease prevention; although, so far nudge experiments have been restricted to issues of hospital hygiene and measles protection (Krisam, von Philipsborn, and Meder 2017). Thus, under the umbrella of the SHI system, prevention is framed as an add-on service for alert and proactive customers.
Typically, SHIs substitute individual health promotion activities such as weight loss programs, yoga classes, or back training and provide benefits (premium payments, smartwatches, vouchers for sports equipment, etc.) for members who regularly participate in preventive check-ups. Any preventive action that deviates from the voluntary principle is extremely contested. In particular, measles protection for children has become a hotly debated issue in German health policy since 500 new cases of measles were reported in 2018. A recent law, adopted in 2019, stipulates compulsory vaccination for kindergarten and school children, educators, teachers, and medical staff. A violation against the law will be penalized with a fine of €2,500 and, in the case of preschool children, the exclusion from the kindergarten.
By adopting the Prevention Act in 2015, policy makers also sought to establish prevention-friendly policy structures. While the law "is no comprehensive public health approach, but a combination of new elements within the logic of the insurance system" (Loer 2016, 793), it provides at least three messages from a citizenship perspective.
First, the law established prevention and health maintenance as key rationales of health policy that traditionally has been oriented toward the cure of illness and disease. As already stated, effective prevention is deemed as the task of each and every citizen. Loer (2016, 792) concludes that "the core belief that every insured person is responsible for his or her health and has to act responsibly with regard to health risks is seen as the basis for the legislation." However, as stipulated by the Prevention Act, citizens' agency toward prevention should take place within the limits of the SHI system. The latter is traditionally characterized by a rather paternalistic stance according to which health-care providers and professionals are in charge of service recipients (Köppe, Ewert, and Blank 2016). Following this logic, the act "authorizes" physicians to identify patients with considerable prevention needs and to issue tailored recommendations for prevention. In addition, physicians may identify persons from vulnerable groups to be considered as "prevention worthy" such as children, young people, and families. Even if it remains people's decision whether to follow doctors' recommendations, the law slightly increases the moral pressure on citizens to make use of prevention offers.
Second, prevention is seen as a national task that requires joint efforts and cross-sectoral cooperation. Based on the goals of the National Prevention Strategy, which emerged from the Prevention Act and has been agreed by multiple stakeholders (health insurance providers, Federal Employment Agency, local authorities, etc.), prevention offers should be developed to reach people "in need of prevention" within their various life-worlds (neighborhood, workplace, school, home for the elderly, etc.). Thus, the act expands the logic of prevention and health promotion throughout German society and supports preventive action from the side of the citizenry. However, the real impact of the National Prevention Strategy has been marginal so far, resulting in the symbolical consideration of health issues in educational plans and school curricula rather than in serious cross-sectorial cooperation.
Third, the Prevention Act stipulates that Germany's SHIs have to increase their financial support by about €30 million per year to further establish an infrastructure for self-help groups and patient organizations. This smaller part of the law deviates from the previous points since it leaves the meaning of prevention and the implementation of preventive policies to nongovernmental and nonmedical organizations. Thus, it breaks, to some extent, with the rule according to which "doing prevention" is a privilege of governments and policy makers; however, self-help organizations that receive state subsidies are in an uneasy situation where they have to fulfill a double role of being service providers as well as critics of the health system (Ewert 2015).
To sum up, for a long time, prevention has been treated as a side issue within Germany's health policy. Characteristically, preventive action was a minor part of the SHI system rather than a citizen duty. So far, this status quo has not been fundamentally changed by the implementation of the Prevention Act.

Collective Crash Course: Prevention Policies during the COVID-19 Pandemic
COVID-19 turned into a collective crash course on the importance of prevention and its range of policy tools. Although comparatively mild from an international perspective, the applied corona "orders" were not "measures" as clarified by Chancellor Angela Merkel (exit restrictions, contact bans, and obligations to wear a mask and keep a minimum distance in the public) and exceeded, by far, every form of prevention that Germans had been familiar with before the pandemic. Hence, it is a big unknown whether the COVID-19 policies will help to further strengthen a preventive mindset among Germany's citizenry. During the public health crisis, policy makers literally addressed citizens, in line with Schneider and Ingram (1993), as "policy targets" that need to be steered in the right direction. Moreover, the corona orders have been executed by the government without having been discussed in Parliament and rapidly implemented by street-level bureaucrats. Nonetheless, the applied mix of (semi-) strict regulations to contain the COVID-19 virus led to extremely high degrees of approval among Germany's citizenry. 2 Hence, at the peak of the crisis, the vast majority of the German citizens demonstrated extraordinary compliance toward the applied set of preventive restrictions. While there has been a continuous protest by a rather small number of "corona rebels," 3 approval rates for strict containment measures remained high when politicians started to discuss lifting the regulations and reached a peak during the second wave of the pandemic. 4 The overwhelming public response to the crisis could, thus, be aptly described as enforced "anticipatory obedience" to be perceived as a high degree of self-responsibility (e.g., practicing hygiene discipline and social distancing) and self-restriction in the face of immediate danger. This assessment is supported by empirical findings concerning citizens' consent to voluntary data disclosure (with regard to their health status) and state surveillance during the pandemic (Hillebrand 2020). COVID-19, therefore, increased a "safety-first-mentality" among citizens. Public acceptance for flexible and adaptive preventive restrictions is also considerably high in Germany, just like citizens' readiness to co-implement restrictive measures (Gollwitzer et al. 2020). Furthermore, ad hoc research with regard to the policy preferences of German citizens revealed that a "large-scale pandemic can induce a substantial willingness to give up freedom for casualty prevention" (Tepe et al. 2020, 9). As a result, Germany's federal health secretary, Jens Spahn, sought to capitalize politically on the temporarily public mood "to shift power away from parliaments toward governments" (Tepe et al. 2020, 9). Spahn urged revisions to the German infection protection law to increase the authority of the federal government in a public health crisis (e.g., to announce exit restrictions, a measure that is traditionally within the competence of the German Länder), made claims for centralized data storage of a government-led tracing app, and promoted the introduction of a clearance certificate that proves citizens' COVID-19 immunity. While none of these suggestions have yet become policy, they may indicate the future direction of preventive policies in Germany, as discussed in the next section.

Discussion: Being a Good Citizen Ahead of Time?
What are the citizenship implications that emanate from the cursory overview of preventive health policy in Germany? Certainly, there is no sufficient evidence to claim the rise of an intrusive "prevention state" where citizens become instrumentalized as mere "co-operators of political will formation" (Peeters 2013, 347-89). On the other hand, we can witness how an unforeseen event such as the COVID-19 pandemic could easily shake up the underlying assumptions of health policy making (Ewert 2019b) and may lead to a broadening of the "state's intervention repertoire" (Peeters 2013, 351). This is because of preventive policies' inherent "expansive logic" that "pushes the state towards an ever more detailed, comprehensive and timely approach to risks" (Peeters 2013, 387). yet, prevention policies do not give birth to a "new citizen" that fully substitutes former role models, they promote change in a surreptitious manner. Setting aside the drastic and mandatory preventive action during the COVID-19 pandemic, doing prevention still remains a voluntary act in Germany. If times are not "about life and death," citizens are strongly encouraged but not coerced to pursue a healthy lifestyle. Free riding in the form of demonstrating prone-to-bad habits (i.e., overeating, smoking, drinking, sedentariness) is still possible without jeopardizing one's citizenship rights. However, free riding is more or less openly classified as irresponsible and uncivil behavior that has to be ironed out by responsible citizens who become the government's prevention role models. Hence, policy makers rely on good citizens' permanent willingness to cooperate, stay alert, and take individually tailored preventive actions. The thrust, therefore, of prevention policies does not only depend on the utilization of restrictive policy instruments; that is, sticks rather than carrots and sermons (Bemelmans-Videc, Rist, and Vedung 2011). Also, new interventions, such as subtle health nudges (Quigley 2014), may work efficiently in line with the ultimate goal of the preventers: a revised status quo where citizens demonstrate "voluntary compliance" invoked by "politically defined norms" (Peeters 2013, 396). Against this backdrop, noncompliant free riders are implicitly perceived as "norm-breakers" who fail to protect their own and, more importantly, public health. In contrast, compliant, "playing-to-therules" citizens are appreciated by policy makers applying a binary view on citizen behavior. Prevention policies succeed if a critical number of citizens anticipate what kind of (health) behavior is expected from them; in such a case, free riding would be effectively delegitimized without compulsion.
As revealed, German citizens had become gradually habituated with the paradigm of prevention before the COVID-19 pandemic. Without applying compulsory measures, citizens are regularly steered toward attitudinal and behavioral change through a mix of prevention interventions. Those policies do not concern citizens' present life in the first place, but the maintenance of a good life in the future. Nevertheless, some target groups (such as the socially disadvantaged and chronically ill people) are deemed to be more in need of prevention than others and are, thus, under the close supervision of policy makers. In addition, prevention policies are partly accompanied by "pedagogical practices" (Newman 2010) assuming that behavioral adaptions could be easily taught to compliant citizens. For example, frequent hand washing-a habit that can be learned and routinized-is regarded as an effective response to counter the lack of hospital hygiene. However, it would be too simplistic to conclude that disease prevention policies in Germany are predominantly based on persuasion and pedagogy. As shown, the policy instrument of the organization (capacity building and the establishment of a supportive infrastructure that facilitates preventive action) plays a role too. Thus, a "better" future where social risks are actively managed and contained requires multistakeholder cooperation (as suggested in the Prevention Act). The latter includes opportunities for citizen participation concerning the strategic orientation of, and forms of, prevention. Hence, citizens have a say on the design of prevention schemes or the content of prevention offers whose fundamental need, however, is not up for debate.
In the face of the COVID-19 pandemic, stricter preventive interventions were indispensable. A large majority of the German citizenry practiced social distancing and stayed at home even before the government officially ordered and implemented them. Thus, it is fair to say that most citizens' behavior came very close to policy makers' version of ideal citizenship to be understood as a "loyal contribution to political will formation and policy proposals" (Peeters 2013, 418). While it is an open issue as to what extent policy makers will draw on this rather submissive demonstration of anticipatory obedience when designing future prevention policies (e.g., to contain the spread of NCDs), the relation between prevention and individual freedom will likely need to be reassessed. In line with prevention's self-reinforcing logic, a side effect of the COVID-19 pandemic could not only be the "normalization of prevention," but gradually more restrictive measures that will keep citizens on a short leash.
If we recall the citizenship concepts discussed in the first part of this article, Germany's prevention policies buttress the notion of "citizenship as an act" (Pykett, Saward, and Schaefer 2010, 527). Hence, prevention is seen as a permanent task that requires the enduring attention and commitment of the citizens. So far, policy makers have addressed citizens in a friendly but firm manner as responsible co-producers of their future health. This does not call into question the legitimacy of social citizenship. It does, however, provide the concept with a new twist. Starting with social rights, preventive policies may enhance citizens' social rights by granting access to new entitlements (e.g., health apps) and services (e.g., health promotion training). However, these rights do not improve citizens' lives in the here and now (as it was envisaged by Marshall) but should maintain citizens' health status in the face of a potentially grim future (e.g., chronic disease). Pointedly formulated, under the prevention paradigm citizens' social rights are by no means to relax (e.g., from the impositions of capitalism), but to stay tuned and active due to imminent challenges. Whether preventive action pays off (i.e., citizens live a healthier life) is a matter of secondary importance; instead, what counts most is their immediate engagement and self-responsibility. By aligning their own civic attitudes and norms with the ones of preventers, good citizens virtually earn their citizenship status (van Houdt, Suvarierol, and Schinkel 2011) in the eyes of the policy makers. With regard to health, this means to pursue a modest, cautious, and self-caring lifestyle that includes regular self-monitoring-characteristics that dramatically gained in importance during the COVID-19 pandemic. Furthermore, citizens' political rights may shift in the course of preventive action: settings-based programs, as stipulated in the Prevention Act and the National Strategy for Prevention, link and promote citizen political participation to the goal of prevention (National Disease Prevention Conference 2018). Finally, prevention policies also convey a moral message to citizens' civil rights since prevention campaigns may result in blaming the victim. In this regard, fines to be paid by citizens who refuse the measles vaccination are the most obvious example. Ethical concerns may also occur if antismoking and healthy eating campaigns lead unintentionally to overt or covert public discrimination of "wrong-doers;" that is, citizens who take the freedom and ignore the presumed common sense of prevention or simply have other preferences (Tengland 2016). In this regard, it will be an interesting test case to observe how the German government will deal with citizens who reject the offer to become vaccinated against COVID-19. While compulsory vaccination is a political nonstarter, Chancellor Angela Merkel declared that restrictions (e.g., a ban on attending concerts, sports events, etc.) are within the realms of possibility.

Conclusion
This article investigated the citizenship implications of preventive health policies in Germany. As argued, prevention-traditionally based on voluntary compliance and self-responsibility-is likely to become stricter in the aftermath of COVID-19; the pandemic turned out to be a collective crash course in the range of available prevention tools. Less voluntary interventions that not only nudge citizens but gently push them toward prevention goals may, therefore, become more attractive for policy makers. As a result, prevention will be further established as a future-oriented policy rationale that requires constant alertness and the commitment of responsible citizens. In light of the prevention paradigm, citizens' civil, political, and social rights become recalibrated. As suggested in this study, tomorrow's good citizens ought to think and act "ahead of time" and in compliance with government prevention policies. While Germany's citizenry overwhelmingly confirmed prevention orders in times of pandemic crisis, it remains an empirical question whether future prevention policies will provoke public dissent and counter policies or abet anticipatory obedience.