commentary

(NYTimes.com)

June 23, 2009

Improve Health, Not the Health Care System

by Dana P. Goldman

One reason that health reform proposals always seem to fail is that proponents promise too much. Reformers declare they will improve quality, lower costs and increase access — all at the same time. This mantra is repeated so often — on both sides of the ideological divide — that the public tends to believe it is possible, when really it isn't.

I want to suggest a new priority — improve health, not the health care system.

This may sound like a parsing exercise, but it is not. Consider the evidence. Many of the greatest improvements in health during the last century had little to do with the health care system. Clean water, public sanitation and reduced smoking all reflect public health interventions that had dramatic benefits.

Cardiovascular disease is another good example. Between 1980 to 2000, the death rate for coronary heart disease was cut in half. But only about half of this reduction came from better medical therapies. The rest — lower blood pressure, lower cholesterol, less smoking, and other factors — came from better behavior and some drugs. And treatment of heart disease is one of our greatest success stories. Our accomplishments in diabetes, cancer and lung disease are not nearly as impressive. So good health is only partially a story about excellent health care.

Advocates of universal coverage often get confused on this point. They equate good health with having health insurance, and cite myriad academic studies. The problem is that these studies don't account for all the other differences between the insured and uninsured — what they eat, where they live, whether they smoke or drink, the amount of stress in their lives, and even their genetic predisposition to disease. No health care system is good enough to fully compensate for bad behavior and poor environmental factors.

With a growing elderly population — and a larger baby boom generation approaching retirement — the prevalence of chronic diseases will rise. If current trends continue, health care costs will consume an ever-increasing share of national income. The future liability of the Medicare program alone is estimated to be $24 trillion over the next 75 years, absent any policy changes.

So what can we do?

Well, the first step is to invest, not in the health care system, but in education. We should take the $120 billion it might cost for universal coverage, and use it to provide earlier education and to improve the quality of education. Better educated people live longer, are less likely to be disabled, and engage in healthier behavior. They also are better at self-managing their chronic disease. And, unlike universal coverage, more education has other valuable benefits to a person and society. Less crime, less divorce and higher earnings — can universal health insurance promise that?

The second place to invest is prevention. Primary prevention has the capacity to slow or reduce the rising prevalence of chronic disease, and simultaneously attenuate the downstream spending associated with it. Equally importantly, however, prevention leads to a life with less disability and more years of an active lifestyle. It just makes a lot of sense to avoid disease in the first place, rather than try to treat it later.

There are also sound economic arguments for a strong government role to prevent disease. Because the benefits of prevention often accrue decades later — long after someone has switched employers or health plans — private plans will skimp on prevention coverage. The government needs to step in to fill this void. Medicare could save itself money, for example, by paying for anti-hypertensive medication before people turn 65.

Perhaps most strikingly, my colleagues and I estimate that if we could roll back obesity to levels seen in the 1980s, we could save up to $1 trillion. We need to find a way to make this happen. One way may involve better medicine — an obesity pill — but it may mean other methods having little to do with health care. Maybe it is an extra hour of physical education at school, or subsidized treadmills in the workplace, or even pedometers for all Americans. Clearly there would be huge returns to a substantial investment to combat obesity.

It is time for us to put the priority on health, not health care.


Dana P. Goldman is chairman and director of health economics, finance and organization at the RAND Corporation. He is also a professor at U.C.L.A.

This op-ed was part of a New York Times Economix Blog post.

This commentary originally appeared on NYTimes.com on June 23, 2009.