The Politics of Prevention

If there’s one thing everyone in Washington can agree on it’s that prevention is good. And that’s about as far as the agreement goes.

As for the rest of it – who is responsible for prevention, how to define prevention, what is the government’s role in prevention, how much to spend on prevention and when to spend it – is not so clear, and wrapped up in the bitter politics (and difficult economics) of the day.

Then, there’s the question of the Prevention and Public Health Fund created by the Affordable Care Act to enable states and communities to try to prevent illness and promote longer, healthier lives. To backers of the law, the fund is an engine for public health, community transformation, and a pivotal part of the effort to create a “health care” system instead of a “sick care” system.

To foes, it’s a “slush fund”, a $13.8 billion monument to everything they don’t like about the 2010 legislation.  It’s $13.8 billion that could easily end up on one of the deficit-cutting chopping blocks.

Even some Democrats are considering cutting some $8 billion from it, as part of a still-elusive larger supercommittee deal.

Dr. Howard Koh, the assistant secretary of HHS, lives and breathes prevention. Board certified in four medical fields (internal medicine, hematology, medical oncology, and dermatology – plus an M.P.H.) he has a keen eye as both a clinician and policymaker for unnecessary and avoidable illness, death and suffering.

The preventable suffering “is a source of tremendous anguish, not just for the patient and family but also for the provider,” he told a recent briefing in Washington sponsored by POLITICO Pro. “There’s got to be a better way.”

For Dr. Koh, the better way can be found, at least in part, through the health reform legislation and the prevention funds. It can be found by expanding access to care. And it can be found through science. All, in his view, are linked.

“We have the potential to expand coverage, which is tremendous, but also really advance the promise of a new system for prevention and public health and that is what excites me the most,” he said.  He called the prevention fund “transformative,” but stressed that grants were being made in accordance with the evidence, the science, and sensitivity to making sure that money is well-spent. (Although in a bow to deficit-cutting reality, he also acknowledged there could be some “possible” but unspecified budget tradeoffs.)

“You are looking at outcomes every step of the way,” he said. “It has to be rigorous.”

“This is a great opportunity. These funds will potentially transform the country,” he said, urging that investments in public health not be put off any longer, that they will pay off both monetarily and in better health.

But where Koh and others in the administration see transformation, some Republicans see boondoggle.

Sen. Tom Coburn, for instance, an Oklahoma Republican and physician who spoke earlier at the same briefing, says the country just can’t afford to be using public funds to build things like basketball courts in the name of public health.  People, he said, should be encouraged to take brisk 15-minute mile walks – for free. “Building basketball courts and all this other stuff… that’s all great,” Coburn said. “[But] our country doesn’t have that luxury right now. There are a whole lot of ways to get exercise rather than spending 10 billion out of the federal government.”

Coburn did endorse some new care delivery models, such as medical homes, that can enhance preventive care and coordination. And he said Medicare, even in the current fee-for-service context, could do a better job of incentivizing prevention – by paying for it.

“The way you incentivize that is to pay a doctor for a prevention visit,” Coburn said. “Medicare pays for some preventive care and screening, and that was expanded under health reform. But it’s virtually impossible for a physician to be paid under Medicare for a good, long talk with a patient on ways to exercise and stay healthy,” Coburn said.

“You can’t get paid for that today,” he said. “There’s got to be a disease you are treating rather than a disease you are preventing to be paid by Medicare. That’s stupid.”

Koh maintained that prevention, writ large, is a major theme for the administration.  The long public health campaign against tobacco, he noted, while not complete, had certainly changed behaviors and saved lives –and money.  “I believe we ignore prevention at our peril. Ignoring prevention is penny-wise and pound foolish,” he said. The country spends $2.5 trillion a year on health. Much of that – heart disease, obesity-related illnesses, tobacco – could be avoided. We can save lives, we can prevent suffering and in a number of cases we can save money too,” he said.

Koh acknowledged that spending on “public health” can be a tough sell in times of austerity, because the returns aren’t always immediate. Indeed, they can be decades away. But sometimes the investments pay off far more quickly than people would imagine. Medicaid in his home state of Massachusetts, for instance, for the past few years has covered smoking cessation counseling, and it started paying off in a couple of years.

Washington politics isn’t the only barrier to change, he said. People’s understanding of public health – and how and why recommendations evolve with the science and evidence – is also problematic, as the recent outcry and confusion over mammograms and PSA tests have made all too clear.

People can understand, say, a new drug or treatment. They don’t necessarily understand that the science of prevention evolves too. Koh called for a more attention to – and research about — health literacy and communication.

He was also optimistic about physicians’ growing understanding of how broken the system is, and the opportunities that health reform offers to begin to fix it, to take better care of their patients, to help them live healthier lives.

And he strongly argued that prevention and public health, while a matter of personal responsibility, is also a matter of collective responsibility. “It has been said that the government is the only part of society that has to care for all people all the time. I would like to think that regardless of your political view on life, we all treasure the gift of health. It is a gift. It is so precious, it is so fragile, you have it today but you cannot assume you are going to have it tomorrow. It has to be protected.”


Contributing Writer Joanne Kenen writes monthly news features for the Health Policy Forum discussing health policy innovation and “what works” in our health care system, as well as the politics of health policy and reform. As a leading nonprofit health care research and consulting institute dedicated to improving human health, Altarum encourages open discussion and debate about the many challenges in health care today. All postings to the Health Policy Forum (whether from employees or those outside the Institute) represent the views of the individual authors and/or organizations and do not necessarily represent the position, interests, strategy, or opinions of Altarum Institute. Altarum is a nonprofit, nonpartisan organization. No posting should be considered an endorsement by Altarum of individual candidates, political parties, opinions, or policy positions.


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