Preventive measures have long been wistfully regarded as under-utilized in improving the nation’s health and restraining health-care spending. But skepticism about their potential is receiving more attention, even as prevention is acclaimed on the presidential campaign trail.
The claim that prevention has been over-sold may appear erroneous, if not heretical, especially when advocates in academe and politics regularly allege missed preventive opportunities for improving health and saving money. Congress periodically chimes in with recommendations for greater emphasis on prevention and increased support for social and behavioral health research at the National Institutes of Health (NIH). But, the public health field, with its emphasis on prevention, has always been the poor relation in federal health spending. The comparison is not exact, but NIH, with its emphasis on diagnosis and treatment, runs on nearly $30 billion a year, while the Centers for Disease Control and Prevention is budgeted for $5.7 billion. Nonetheless, in this year’s presidential campaign, the preventive theme echoes loudly as candidates strongly endorse greater use of preventive measures in their proposals for health-care reform, particularly in regard to costs.
The latest and perhaps the most cogent call for skepticism appears in the February 14 New England Journal of Medicine, in a lead article titled “Does Preventive Care Save Money? Health Economics and the Presidential Candidates,” by Joshua T. Cohen and Peter J. Neumann, Tufts-New England Medical Center, and Milton C. Weinstein, Harvard School of Public Health. The authors cite estimates of 900,000 deaths annually — 40 percent of total U.S. mortality — attributable to smoking, excessive use of alcohol, poor diet and physical activity.
Based on a review of 599 published articles “that properly discounted future costs and benefits” of preventive measures, they conclude that “opportunities for efficient investment in health care programs are roughly equal for prevention and treatment…. Some preventive measures save money, while others do not, although they may still be worthwhile because they confer substantial health benefits relative to their cost. In contrast, some preventive measures are expensive given the health benefits they confer.”
The authors note that health counseling and screening for disease can be cost-effective in high-risk groups, but less so for others. Turning to the prominence of prevention in campaign oratory, they criticize “broad generalizations made by many presidential candidates” as misleading and caution that “although some preventive measures do save money, the vast majority reviewed in the health economics literature do not.”
A similar message was delivered in a paper by Louise Russell of Rutgers University, “Prevention’s Potential for Slowing the Growth of Medical Spending,” published last October by the National Coalition on Health Care, a broadly based coalition of health-related organizations (www.nchc.org). Crediting vaccines as “among the most cost-effective preventive interventions,” the author argues the costs of large-scale screening and preventive medications for heart disease can be far higher than is generally realized when all costs, including patients’ time, are considered. “Annual screening for cervical cancer, usually a slow-moving disease, adds greatly to medical costs, with little additional health benefit, compared to screening less often.” Counseling for diabetes prevention can be effective, but adds “substantially to medical costs: $192,000 for each healthy year gained, in 2007 dollars.”
Russell concludes that “the evidence does not support the commonly accepted idea that prevention always, or even usually, reduces medical costs — although it sometimes does. Most preventive interventions add more to medical costs than they save, at the same time that they improve health.”
Why, then, the frequent salutes to prevention in the presidential campaign? As the NEJM authors note, Hillary Clinton’s health plan calls for a “focus on prevention: wellness not sickness.” Barack Obama states that “too little is spent on prevention and public health.” And Mike Huckabee says prevention “would save countless lives, pain and suffering by the victims of chronic conditions, and billions of dollars.” They don’t mention John McCain, but he, too, is for prevention, stating on his campaign web site that prevention can spare “millions … from ever developing deadly and debilitating disease.”
Gloomy forecasts about health-care economics have so often been fulfilled that they attract little notice. The most recent, from the Centers for Medicare and Medicaid Services (CMS), might ordinarily be expected to induce economic despair, if not panic, but it arrived and sank out of sight in February with little notice. The CMS reported that health-care spending rose in 2007 by 6.7 percent, to consume 16.3 percent of the gross domestic product (GDP). In 2017, the health-care bite will rise to 19.5 percent of the GDP, according to the forecast. In every year over the coming decade, the rate of increase in health-care spending is expected to exceed the nation’s overall rate of economic growth. At present, some 47 million Americans lack health insurance. With the federal budget now severely constrained, and tax increases politically dangerous, cost-saving miracles are much in demand. Hence, the appeal of prevention.
Do the many calls for reform and embrace of prevention in the election campaign presage, at long last, major changes in health-care American style? The only certainty is that a major political battle lies ahead, whoever wins the election. The sectors that now thrive on the nation’s patchwork system of health care are not inclined to surrender their advantages. The Pharmaceutical Research and Manufacturers Association, which represents the major drug firms, increased its lobbying expenditures by 25 percent last year, to a total of $22 million. The increase was attributed to lobbying against patent reform and a prescription drug-safety bill, and lobbying for reauthorization of a federal program that provides health care and drugs for poor children. ♦