The biggest threat to the nation’s health is not avian flu, AIDS, or bioterrorism. It is preventable, chronic disease. Roughly 70 percent of health costs and deaths are attributable to smoking, obesity, and health problems that could be prevented.
Most Americans do not know about or value prevention. One out of five diabetics and one out of three hypertensives are unaware of their condition. Those that do know what they should do often skip treatments or steps to improved health. Prevention’s perceived value is low since its potential benefits are distant.
The answer, according to conservatives, is increased individual “ownership” of health care dollars. Our failure to promote prevention, they reason, lies in government mandates and over-insurance that de-emphasize personal responsibility. Why diet when insurance pays for gastric bypass surgery? Why exercise when you can take a pill to lower your blood pressure? When people can be treated for any problem with first-dollar coverage, goes the reasoning, they may not prevent those problems in the first place. As one conservative says, the incentives are upside down. Therefore, if individuals reap the financial as well as the health rewards of prevention, they may be motivated to action. In policy terms, this means replacing traditional insurance with health savings accounts linked to high-deductible health plans.
Problem is, this “solution” has not seemed to work in reality. Information provided to enrollees in these consumer-driven health plans is infrequent and inadequate to help consumers make smart decisions.
Even Americans who know about preventive medicine tend to use it less when it costs them money. One study showed that even $10 co-pays caused a significant reduction in the use of mammograms among seniors. This is why effective health insurance plans often make prevention free or linked with some monetary benefit.
High deductibles also appear to harm efforts designed to forestall or prevent complications of an established disease as well: People with arthritis, heart disease, high cholesterol, and asthma were two to three times as likely to not fill a prescription due to cost when enrolled in a high-deductible plan versus a traditional insurance plan.
Even the insurance industry doesn’t stand behind the belief that consumer-driven health plans drive improved prevention. It recently issued a report focusing entirely on how high-deductible health plans are increasingly waiving deductibles for preventive care. This is more than an exception to the rule: It repudiates the theory behind these plans.
There is a better way. Prioritizing prevention means paying for services wherever, whenever, and for whoever needs it. It means investing in communities, schools, and workplace wellness efforts. And it means moving beyond private insurance as the sole solution: those companies simply have no incentive to invest in prevention today that benefits others later.
For additional reading:
Elise Gould, “Consumer-Driven Health Care is a False Promise,” Economic Policy Institute, October 11, 2006.
Marjorie Ginsberg, “Rearranging The Deck Chairs: Consumer-directed health care confronts the problems of health insurance,” Health Affairs- Web Exclusive, October 24, 2006.
James C. Robinson, Ph.D., “Health Savings Accounts — The Ownership Society in Health Care,” New England Journal of Medicine, September 22, 2005.
Jeanne Lambrew and John Podesta, “Commentary: The Wellness Trust,” Forbes.com, September 4, 2007.
Background Basics on Prevention
What is Prevention? In the United States, more than 125 million people suffer from a chronic disease such as hypertension, heart disease, cancer, or diabetes. Many people also suffer from acute diseases that can be prevented through vaccination or other means (e.g., daily aspirin use to prevent heart attacks). Preventive medicine attempts to reach these individuals before they become patients or develop disease complications. There are three levels of preventive medicine:
* Primary prevention is focused on preventing the actual occurrence of a disease or injury (immunization against measles or influenza, for example)
* Secondary prevention identifies those with significant risk factors for particular diseases, such as cancer, hypertension, or diabetes, and helps them manage their future health
* Tertiary prevention provides care for those with an established disease to prevent or forestall progression and complications (treating high blood pressure before it leads to stroke, or diabetes before someone develops cardiovascular or kidney disease, for example).
Prevention measures can be performed in a clinical setting or undertaken by the larger community. Clinical prevention includes services performed by medical professionals—mammograms, colonoscopies, and cholesterol screenings, to name a few. Community prevention extends to population-based services to limit disease, injury, or disability—measures such as efforts to build playgrounds and bike paths to promote physical activity, and tobacco taxes and use restrictions to reduce smoking.
The National Commission on Prevention Priorities ranks clinical prevention services based on cost and health effectiveness. Their results have led to a core list of recommended preventive services (see Table).
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