"An ounce of prevention is worth a pound of cure."
The famous quote from Benjamin Franklin is one we hear often in health care, and the Patient Protection and Affordable Care Act (ACA) will give us a new opportunity to put prevention into practice. If we are really serious about improving the health of Americans and communities across this nation, providing health insurance under Obamacare -- while an important first step -- will not be enough.
As the ACA begins to roll out across the nation, an estimated 14 million Americans will be eligible for health care coverage through a state or the federal exchange for insurance coverage starting in January 2014. At the same time, we know that only 10 percent of the overall health outcomes of a community are due to the healthcare delivery system, on which almost $3 trillion is spent yearly. To tackle the thorny issues that create long-term improvements in health and drive down costs, we must look at the underlying factors that affect health and invest in strategies that we know can prevent chronic diseases, such as obesity, diabetes, cancer and heart disease. Better health will only happen when we address some of these factors, such as an individual's behavior, and the underlying social factors that affect health.
Change is Difficult, But Necessary
The problem is, changing behaviors, which accounts for over half of health outcomes, is hard. To do this, we must provide education coupled with the appropriate incentives and policies that keep us healthier for the long-term. For example, to address overweight and obesity, access to affordable fruits and vegetables and safe places to walk and play are needed. Similarly, policies that eliminate smoking in workplaces and other public settings and raise the price of cigarettes are steps in the right direction to prevent smoking - a leading cause of cancer and heart disease.
In addition to insurance coverage, the ACA provides incentives to form accountable care organizations, which are integrated health delivery systems made up of hospitals, clinics, doctors and nurses united to provide more efficient quality care for the patients in its system. Dr. Donald Berwick, former head of the Centers for Medicaid and Medicare Services, has proposed a "triple aim" for these new health care systems: reduced costs, better quality and patient care, and improvements in population health.
Broader Definition of Population Health Needed
But if we define population health too narrowly, we will only address the health of individuals within the delivery system and we'll miss a major opportunity to focus on the entire community. Instead, a broader definition of population health that includes everyone in the community is needed to prevent chronic diseases, which are the growing driver of health care costs, from occurring at all. We need to invest as much in prevention, health promotion strategies and in safe, walkable communities where people have access to safe drinking water and clean air as we invest in good clinical services. Right now, the investment in prevention in community settings is less than 5 percent of the total spent on healthcare.
Align Health Delivery and Public Health Systems
Future health reform efforts need the collaboration of state and local health departments with the health delivery systems. A first step in the process of health delivery and public health systems working together is to map where their patients of health delivery systems live and then form partnerships with the local health departments in those communities to collaborate on improving specific health outcomes. Aligning the health delivery system with public health strategies in the community is the only way to produce the best health outcomes for patients and the community at large. States, such as Colorado, Oregon and Vermont, and health delivery systems, such as the Cambridge Health Alliance and Denver Health, are leading the way in developing collaborations between delivery systems and public health entities.
The Affordable Care Act could be a real opportunity to reduce long-term health costs and improve the health of the entire U.S. population. But to do this, we must look beyond the traditional models and invest in public health at the community and state level. We should not wait to spend more on cures for diseases that could have been avoided. To save money and lives, we need to follow Benjamin Franklin's advice -- invest in prevention first.
Deborah Klein Walker is a Vice President and Senior Fellow at Abt Associates. She served as Assistant and Associate Commissioner for 16 years at the Massachusetts Department of Public Health. She is a former president of the American Public Health Association and the Association of Maternal and Child Health Programs, and the 2012 winner of the APHA Martha May Elliot award for lifetime achievement in maternal and child health. The opinions expressed are her own and do not reflect those of Abt Associates.
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