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Gary H. Cohen Headshot

The Elephant in the Waiting Room

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Amid the Obama administration's mismanagement of the electronic enrollment process in the health care marketplace and Republicans' obsessive calls for repealing the Affordable Care Act, neither party is addressing the fundamental flaw in the entire health care system -- we only know how to treat sick people.

Even once the enrollment process is running smoothly and we settle into the reality that health care reform is happening, we will still be left with the harsh facts that the entire American health care system is a sick care system.

We manage chronic disease. We don't prevent it.

For every dollar spent on health care, 70 cents is spent for treating diseases and 4 cents is spent on prevention. Moreover, we spend more money on health care per capita than any nation on earth, yet our health statistics are worse than those of 17 other industrialized countries. Cancer rates are 1 in 2 for men and 1 in 3 for women. One-third of all Americans are either overweight or obese, contributing to diabetes, heart disease, stroke and a variety of other conditions. Asthma rates for kids continue to climb and learning disabilities affect 1 in 8 children.

Given current health trends, we will bankrupt the health care system within a generation due the epidemic rates of chronic disease and escalating costs of treating them -- with or without the new health care laws.

To its credit, the Affordable Care Act does recognize this problem and has designated "population health" as one of its three core aims (the other two being cost containment and improving the patient experience).

This is an important opportunity for health care providers and insurers to look beyond their own four walls and see what's making people sick in the first place.

Why are the cancer rates so high? According to the Center for Disease Control's nationwide database, average Americans have scores of toxic chemicals in their bodies. We absorb these toxins through our food, our air, and our home and consumer products. Independent tests by the Environmental Work Group confirm that American children are being born pre-polluted, sometimes with more than 100 chemicals in their bodies, many of them linked to cancer, birth defects and reproductive problems. What kind of society allows these chemicals to trespass into the womb? How can we ever hope to prevent cancer if we are not committed as a nation to protecting American women and children from poisonous chemicals?

Americans have the second highest obesity rates in the world. In many of our communities, you can go down to the corner store and get tobacco, alcohol, guns and junk food, but you can't find fresh fruits and vegetables, the consumption of which is a proven strategy for lowering the risk of diabetes and obesity. If we as a society can't create the conditions for our citizens to eat healthy food, then we should expect they will continue to become overweight and chronically ill.

Poverty remains the most important indicator of poor health. Children living in poverty have a higher likelihood to live in dangerous neighborhoods, have above-normal weight, and experience a variety of other social stressors that contribute to disease.

Under the Affordable Care Act, we have a chance to move upstream and address the social and environmental factors that are making people sick in the first place.

American hospitals can start by modeling the transition to a healthier environment in their own facilities. They can build cancer centers without carcinogens and pediatric hospitals without chemicals linked to asthma and birth defects. They can eliminate junk food and sugary beverages in their cafeterias and use their purchasing power to detox their supply chain. They can reduce their addiction to fossil fuels, which contribute to both immediate health impacts as well as climate change. They can become early adopters of renewable energy that will provide health benefits to all of us for generations to come.

We also need a new social contract between health care institutions and the communities they supposedly serve.

Hospitals and insurers can pay to detox our homes and schools and guarantee access to healthy and sustainable food in our communities. They can implement programs to support their own employees' health and as well as educate and incentivize their patients and members to stay healthier. They can use their economic clout to support businesses that protect their own employees' health through safety and environmental programs. They can also co-finance community-based renewable energy projects that support greater climate resilience, cost savings and reduced greenhouse gas emissions.

These prevention programs also address another key aim of health care reform, which is to reduce the cost of health care.

As it turns out, it's cheaper and more effective to eliminate moldy carpet and pesticides in people's homes that contribute to asthma rather than continue to treat children repeatedly in the emergency room. Its cheaper and more effective to write prescriptions for healthy fruits and vegetables than perform bariatric surgery on obese patients. Prevention is far more cost-effective than treatment.

Health care represents nearly 20 percent of our entire economy and is growing. If we can redirect this one sector that has "healing" as its mission to address the social and environmental harm in our communities that contribute to our epidemic of chronic disease, then we can truly reform our health care system.

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