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Stephen A. Brunton, M.D., FAAFP Headshot

Prevention in Health Care: Reforming the Debate

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It seems like just yesterday that the presidential campaign was dominated by partisan debate over the philosophical, moral and political implications of "Obamacare," with both sides taking a stance that victory by the other would spell the end of America as we know it. Now, as the roll-out next year of the Affordable Care Act finally draws near the debate has shifted to a much more practical focus; how (if?) the implementation of reform will actually work, and how (if?) we will pay for it.

Obama himself has conceded there will likely be "glitches," with others taking much more dire and extreme views. But one thing that is being lost amid the shouting has been the gradual slashing of one of the ACA's most groundbreaking and potentially lifesaving components -- the $15 billion Prevention and Public Health Fund.

When it was initially announced, the Fund represented the most significant U.S. government commitment to prevention ever made. Then, amidst "fiscal cliff"/sequestration issues and a flood of negative criticism, it was promptly cut by $6.5 billion in February to help reduce the federal deficit. Then last month the administration announced that it would use nearly half of the 2013 Fund dollars to build the federal health exchange.

Beyond the political and budgetary challenges in Washington and the debate around the relative merits of various aspects of the ACA, these reductions to the Fund are representative of a broader alarming shift in our health care system: a growing desire to cast prevention as expendable and as synonymous with wasteful spending.

Recently, many in the medical community have unfairly criticized a number of preventive measures -- creating a controversy in the process. Just look at the highly charged reactions from both the physician and patient communities over recent U.S. Preventive Services Task Force (USPSTF) guidelines narrowing the recommended window for patients to receive breast cancer screenings. And many of the other USPSTF guidelines (such as screening for many cardiovascular diseases) are more than half a decade old, creating further controversy and in the process muddling the debate about what preventive measures are appropriate based on the latest science in the process.

The reality is that many of the critics of such preventive care, and many in Washington, are taking a short-sighted view that does not adequately account for long-term costs to the system, or long-term health of patients. Consider that five diseases cause more than two-thirds of all U.S. deaths annually -- heart disease, cancer, stroke, chronic obstructive pulmonary disease (bronchitis, emphysema) and diabetes. Chronic diseases like these also account for roughly 75 percent of the nation's spending. However, they are also among the most preventable through early detection and screenings.

Looking closer at a specific example, stroke is the fourth leading cause of death in the country, and costs nearly $75 billion to the system -- in spite of the fact that roughly 80 percent are preventable. When you consider this math, it's clear that adopting an approach where we only address symptoms once they are obviously apparent makes little sense, and that the recent flurry of vitriol decrying screenings is a prime example of how the anti-prevention trend has gotten out of hand.

As noted in a recent report by health care-focused investment bank Triple Tree, consumers wishing to invest in prevention due to their individual circumstances are increasingly turning to organizations offering solutions outside of the traditional spectrum -- such as the local community screenings offered by companies like Life Line Screening. As noted in the report, these types of collaborations between community-based care and traditional doctor-office and hospital-based care makes sense, and should be encouraged.

Like anything, when it comes to health care, there is a careful balance that needs to be achieved between doing what is best for the patient, and being prudent in managing costs to the system. There is certainly a valid and important point to be made that we all need be working together to ensure that preventive measures do not lead to costly and unnecessary procedures or actions. But currently it seems that the balance has shifted so drastically towards the cost-cutting end that the logic of preventive measures has been drowned out.

In order to truly address costs in a manner that doesn't come at too steep a price for the patient, it's necessary to recalibrate the debate and recognize that prevention is a tool that needs to be utilized appropriately across the medical spectrum -- not thought of as the first casualty of trimming the health care budget.