PREAMBLE

The typical centerpieces of health care reform efforts are financing of health insurance coverage and access to care. While financing and access are, indeed, critical and necessary elements of health care reform, by themselves, they fall short of our ability to achieve the real goal – improving the health of all Americans. Indeed, much of the criticism of our current system is that for all we spend, our health outcomes lag behind those of other nations that spend much less.  

With our increased awareness of the determinants of both good and endangered health, we should not yet again miss the opportunity to ensure that reform efforts take account of the full range of mandates to our health system – promoting health, preventing disease, treating the sick, and ameliorating the consequences of illness. Comparisons with other countries’ per capita spending and health status indicators make clear, however, that spending more on treatment alone will not bring about commensurate improvements in health.

More important than increasing our overall healthcare spending is spending our precious resources on the things that contribute the most to improved health. This means prevention. Delivering preventive services that have been proven effective is essential if we are to optimize the health of our citizens. Unfortunately, low utilization rates for many important preventive services reflect the lack of emphasis that our current system gives to providing these services. For example, only ten percent of female Medicare beneficiaries have been screened for cervical, breast, and colon cancer and been immunized against influenza and pneumonia;¹ the majority of Americans at risk for colorectal cancer are not being screened; and in 2005, 78% of Hispanic adults and 63% of black adults over age 65 reported never having received the pneumococcal immunization compared to 38% of white adults over 65.^2,3,4 

In keeping with society’s natural attention to rescuing those in distress, historically, the debate over health care has been dominated by those most concerned with diagnosis and treatment. As awareness grows, however, that it is often possible to prevent the distress in the first place – improving health status in a more cost-effective manner – support for policies to expand the delivery of preventive services is increasing.

Universal coverage is an important component of a just and equitable healthcare system, but it is not the ultimate goal. In fact, health care reform that simply aims to extend coverage to all Americans but fails to place more emphasis on prevention is likely to be even more costly and unsustainable than today’s system. The end we seek is the preservation and improvement of health. So, in considering what a reformed and more effective health system should look like, we need to ask what more we might be doing that would actually improve health, especially the prevention of disease and its consequences.

Investing in prevention means supporting the two approaches that health professionals use to promote health and prevent disease, namely, (1) improving the quality and quantity of clinical preventive services delivered to individual patients and (2) implementing community preventive services, programs, and policies aimed at broad populations or sub-populations.

Clinical preventive services are delivered in a medical setting (most often a physician’s office or clinic) by a healthcare professional. They include counseling individuals to maintain healthy lifestyles and avoid unhealthful behaviors, immunizing children and adults to prevent future disease, and screening individuals to identify diseases that are present but not yet symptomatic. Expanding and improving the delivery of clinical preventive services would enable millions of Americans to live longer, healthier, and more fulfilling lives. It would also lead to a more effective use of the nation’s health resources. This is because most clinical preventive services are very cost-effective, and certain preventive services actually save more money than they cost.  

The second approach to promoting health is to utilize policies, programs, and services that aim to improve the health of the entire population or specific sub-populations. Target groups for community preventive services could include, for example, all Americans, residents of a state, municipality, or neighborhood, or even those at a school or worksite. While discussions about health reform typically focus on the traditional healthcare system (i.e., hospitals, insurers, healthcare professionals, etc.), the largest gains in health status will result when the nation addresses the many societal conditions that lead to unhealthy lifestyles and poor health. These include cultural, environmental, and economic forces that contribute to the leading preventable causes of death and disease, namely, tobacco use, poor nutrition, physical inactivity, and alcohol and drug abuse. In fact, many of the most significant advances in health have resulted from policies aimed at health threats that are not typically addressed in traditional healthcare settings, such as clean water, speed limits, seat belt use, clean air, food and restaurant inspections, fire prevention and building standards, etc.

Ensuring health insurance coverage for each person is an important national responsibility, and research shows that having health insurance does impact health, especially when lack of coverage is an impediment to obtaining important immunization and screening services. Insurance coverage of high-value clinical preventive services, such as those recommended by the National Commission on Prevention Priorities, can help lead to a healthier population. High-value clinical preventive services are those services that, based on extensive evidence reviews, are proven to be effective and that offer the greatest improvements in health and the best cost value. (Examples of high-value clinical preventive services include tobacco cessation counseling, childhood and adult immunizations, colorectal cancer screening, and counseling about aspirin therapy to prevent heart disease.) 

Considerable and compelling evidence also makes clear, however, that community preventive services aimed at populations have an enormous impact on health and are extremely cost-effective. The nation will get a much greater return on investment by focusing on health improvements in communities, schools, and worksites rather than focusing solely on what occurs in traditional healthcare settings, such as doctors’ offices and hospitals.

The health reform agenda that Partnership for Prevention is promoting affirms the need for a health system continuum that goes from community-based health promotion and disease prevention, to primary care-based health promotion and disease prevention, to primary-based early detection and treatment of disease, to specialty care diagnostic testing, hospital care, emergency care, and end-of-life care.

Footnotes: