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Prevention Battles For Survival In Health Reform Legislation

First Posted: 10/17/09 06:12 AM ET Updated: 05/25/11 02:55 PM ET

Obama Exercise

One of the easiest ways to lower health care costs, as President Barack Obama frequently points out, is to take steps so that people don't get sick in the first place.

But now, as the debate over health care legislation hits new levels of intensity, questions are being raised about how the government can best go about preventing illness, how much political will exists for such an investment, and how much money it will really save in the long run.

Preventive health care falls into two wide categories: Wellness, which encourages lifestyle changes that can prevent or even reverse common illnesses; and early screening. They each have their own advocates, their own value propositions, and their own accompanying political dynamics.

The biggest bang for the buck may come from changes that can be made to personal habits and choices. A 2008 report from Trust for America's Health, for instance, found that investing $10 per person per year in proven programs promoting physical activity, better nutrition, and smoking cessation could save more than $16 billion annually within five years -- for a return of $5.60 for every $1 spent. Multiple studies have shown that more than half the cases of type 2 diabetes could be avoided with simple lifestyle changes.

Indeed, for some in the medical community, an intensive lifestyle intervention often is regarded as an effective form of treatment. The capacity to exercise and eat well, for example, can go a long way to reversing chronic diseases - a relatively low investment for a big cost-saving outcome.

Politically, pushing for wellness and fitness is even more palatable, having bridged the widest of partisan divides. A staple of the Obama health care stump speech, the topic has also found its way into Sen. John McCain's, (R-Ariz.) pitch as well.

"I mentioned long-term cost reductions," the Arizona Republican declared at a town hall event this week. "What are those? Wellness and fitness. There's a guy who's gotten pretty famous lately and he's the CEO of Safeway. You know what they have done at Safeway? They have programs and policies that incentivize their employees to practice wellness and fitness. Not to smoke, to work out, to do exercise, to get regular physical checkups. And they give them cash rebates and they give them policies that fit their particular needs. And guess what? Safeway's health care costs have gone down. Why can't we adopt that on the national scale? Why went we reward people for practicing wellness and fitness?"

Two weeks ago, meanwhile, a bipartisan group of Senators introduced the "Take Back Your Health Act," which would create a new program within Medicare to promote "comprehensive lifestyle programs" designed to lower the likelihood of chronic disease.

And yet, even with the most obvious of reforms, politics has a way of complicating matters. While House and Senate aides say billions of dollars will be devoted to wellness and fitness programs and promotion in a final health care reform bill (no exact figure currently exists), others think a much larger investment is needed.

"I'm most interested in paying for intensive lifestyle interventions to reverse heart disease, diabetes, prostate cancer/breast cancer, and obesity, as these account for 75% of the $2.1 trillion in 'health' care costs last year," said Dr. Dean Ornish, the Medical Editor of The Huffington Post. "Now, only 5 percent of the $2.1 trillion are spent for anything related to prevention; clearly, there is a lot of room for doing more."

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The funding of early testing, screening and treatment -- for illnesses like cancer and heart disease - has been framed by the President and his allies as a major cost saver in the health care system.

"For most people, it is just common sense that if we can use cost-effective screenings and other up-front interventions to prevent tens of millions of occurrences of cancer, diabetes, and cardiovascular disease, then we are going to slash health care costs significantly," Sen. Tom Harkin, (D-Iowa), told the Huffington Post in early August. "We are going to create a reformed health system that - in a systematic and sustained way - bends the cost curve and restrains health care spending in the years ahead."

In recent weeks, however, Harkin's position has become a subject of contention. A Congressional Budget Office analysis released last month warned that some of these preventive techniques could actually cost taxpayers more money than they save.

"Although different types of preventive services have different effects on spending, the evidence suggests that for most preventive services, expanded utilization leads to higher, not lower, medical spending overall," CBO's Director Douglas Elmendorf wrote in a letter to Rep. Nathan Deal, (R-GA).

And a study published on Tuesday by Health Affairs journal called into question the money that could be saved by providing aggressive and prolonged medical services to Type 2 diabetes patients.

Respected members of the medical and academic community have also raised concerns that if expensive tests, screening and medical consultations were made free or cheap, they would become overused.

"I'm afraid most of the research supports the CBO point of view," Linda Bergthold, a health policy consultant and researcher who served on Hillary Clinton's Health Care Reform Task Force in 1993, told the Huffington Post. "I think one of the more interesting arguments against covering prevention in a broad way is the one the CBO makes -- that if you pay for [these services, people] will come, and they will come again and again."

Aides on Capitol Hill and in the White House, as well as a several other health care analysts interviewed for this piece, scoffed at the notion that prevention is overrated. For starters, they noted, legislation passed by the Senate Health, Education, Labor and Pensions (HELP) Committee differentiates between preventive services that are proven to work and those that don't. Funding would go to the former and not the latter.

In addition, while Tuesday's study called into question the cost-benefit equation of treating Type 2 Diabetics, it also noted that money spent on care and preventive services would be recovered over 25 years (after which there would be net savings.)

Moreover, there are a host of studies conducted by reputable members of the medical community that hail prevention as a solid investment.

"Because the benefits of prevention often accrue decades later -- long after someone has switched employers or health plans -- private plans will skimp on prevention coverage," wrote Dana P. Goldman, the chairman and director of health economics, finance and organization at the RAND Corporation. "The government needs to step in to fill this void."


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Perhaps the biggest obstacle advocates of both wellness and screening face is that the debate over health care reform has been complicated by pledges from the president and Democrats in Congress that the final legislation will be deficit neutral. That means that initiatives live and die based on whether the Congressional Budget Office scores them as costing - or saving - money. And the CBO won't score preventive treatment as creating savings under the rationale that there is no template to determine an accurate accounting.

"The CBO only scores things if they have happened before. So if we had done prevention earlier they would have scored it," said one slightly irritated White House aide. "But because we haven't, they won't. It's like if basketball fans refused to project how many more wins the Lakers would have when Shaq and Kobe first teamed up. Everyone knew the team would be better. They were going to win a championship. But because they hadn't played together before people for some reason refused to say how many more wins that would translate into."

In its current incarnation, the HELP Committee bill includes a prevention and public health investment fund that ramps up over 5-years to $10 billion a year, a portion of which would go to promoting wellness and fitness. The bill would require private insurers to cover preventive care deemed most effective by an advisory committee of the Department of Health and Human Services.

The Senate Finance Committee is expected to include money for Medicare and Medicaid to cover preventive services. The House's health care package - even after negotiations with Blue Dog Democrats - is estimated to put $8 billion behind preventive services in Medicaid and another $2.8 billion in eliminating preventive care co-pays in Medicare over the next decade.

But if prevention is scored solely as a cost, rather than a savings, then some on the Hill worry that the final dollar figure for these services will be pared down.

"It is frustrating to say the least," one Senior Democratic aide said of the rigidity of the CBO's policy. "My words aren't conveying how frustrating it is. At least now, compared to the past, we have at least some data [so that] members of the press, Senators and Representatives say this makes sense."

This, in the end, may be prevention's saving grace. While Elmendorf's letter will likely force a round of questions about the utility of paying for specific procedures, the political juice is still there to see at least a decent amount of funding in the final legislative package.

After all, even the President's Republicans critics are on record offering their philosophical support. A focus on prevention, former House Speaker Newt Gingrich and former Arkansas Governor Mike Huckabee wrote in an August 2007 oped, "would save countless lives, pain and suffering by the victims of chronic conditions, and billions of dollars."


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