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Understanding Prevention

By Dr. Charlie Preston
. 1 Comment(s)

Last night, Politico broke a story ( about using health reform’s new $15 billion prevention and public health fund to pay for a temporary Medicare doc fix. The fund is one of the major targets of opponents trying to defund the law.

In a similar attack on prevention, Sarah Palin made tough comments about Michelle Obama’s fight against childhood obesity. In an interview, she said,

“Take her anti-obesity thing that she is on. She is on this kick, right. What she is telling us is she cannot trust parents to make decisions for their own children, for their own families in what we should eat. And I know I’m going to be again criticized for bringing this up, but instead of a government thinking that they need to take over and make decisions for us according to some politician or politician’s wife priorities, just leave us alone, get off our back, and allow us as individuals to exercise our own God-given rights to make our own decisions and then our country gets back on the right track”.

As a preventive medicine physician, I find these comments to be incredibly frustrating. But I think they signify a broader problem with prevention messaging—most people just don’t get what we are trying to do. Sarah Palin thinks this is some proxy for a fight about the role of government. Others see it as the federal government gone wild. Take the comments of Senator Mike Enzi for example. Referring to the prevention provisions in the Affordable Care Act, he called them “new pork barrel spending” and said, “the bill will pave sidewalks, build jungle gyms, and open grocery stores, but it won’t bring down health-care costs or make quality coverage more affordable”.[1]

The reality is that prevention has always been a difficult subject to understand. It is very popular, and in fact, recent polling showed that 71% of Americans supported an increased investment in it.[2] But now that we have that big investment, most people, including Palin and Enzi, don’t understand what prevention looks like in action. Perhaps that’s why we only spend about 3% of our health care dollars on it.

Moreover, some say that prevention isn’t cost saving. But there is no dispute that it is a good economic value. [3]  In other words, the dollar can be stretched further with prevention than it can with other lower value services. Just 5 clinical preventive services– colonoscopy, mammography, flu shots, aspirin, and smoking cessation counseling– are relatively inexpensive compared to the good they can do. If these were used 90% of the time, more than 100,000 lives could be saved each year. Current estimates are that they’re used about half of the time or less.

Obama’s prevention campaign against childhood obesity is predominantly meant to raise awareness. It isn’t meant to tell parents what to do. It is meant to say that there is this really serious problem out there that frankly a lot of parents might not even know is affecting their children. In fact, research shows that the majority of parents recognize childhood obesity as a serious problem but that nearly 85% of parents of overweight children think their child is at a healthy weight.[4] Obama’s campaign is also designed to mobilize resources. Money is needed for research and interventions that can halt the epidemic. Would Palin have quarreled with Nixon’s “War on Cancer”? In many ways it too was designed to raise awareness and mobilize resources.

Regarding Senator Enzi’s comments, yes, the law will build sidewalks and jungle gyms and grocery stores. These are important things to do because more sidewalks will lead to more walking. Jungle gyms will lead to more children exercising. And grocery stores will give low-income communities more options than just high calorie but nutrition lite fast food. The diseases that stem from not eating right and exercising regularly, like heart disease and diabetes, make up 7 out of 10 deaths in the United States and account for 75% of all our health spending. If we invest in more high value services like the preventive services already mentioned, we will get more bang for our health care buck, and thus, keep health care costs and premiums lower than in a system that didn’t make these investments.

Ultimately, what is needed is a better explanation of what prevention is, what it looks like in action, and why it is necessary. The Affordable Care Act includes unprecedented resources for prevention activities—in the clinic, the community, and in the workplace. If we as physicians and public health experts don’t get the word out, that money will go elsewhere because people won’t understand what we’re doing with it. It isn’t about government. Rather, it is about everyone working together, medicine, public health, and the public, private, and non-profit sectors to mobilize against death and disease.

[1] Bristol N. US targets disease prevention in health reforms. Lancet. 2009 Dec 12;374(9706):1957-8.

[2] “American Public Supports Investment in Prevention as Part of Health Care Reform”.  Web.  Accessed: 11/28/2010.

[3] Woolf SH. A closer look at the economic argument for disease prevention. JAMA.2009 Feb 4;301(5):536-8.

[4] Whyte, John.  “Childhood Obesity: What We Don’t Know Can Hurt Us”.  Web.  Accessed: 11/28/2010.

Share Your Comments


  1. Lisa Plymate

    This is more than a stand against public health. It is a foot-in-the-door toward destroying by defunding the Affordable Care Act. We need to take a strong general position, that Congress should not destroy portions of the ACA to pay for other health care costs. They should find another source for paying for the SGR 'fix.' It's true that it's expensive ($17 billion) to keep Medicare payments at their current level over the next year, and that if this is not covered, many patients will lose their access to care as doctors decide not to see Medicare patients. It's also true that we need a more permanent fix -and that we have to cut costs of the program, which we plan to work on through other components in the Affordable Care Act. But in the mean time, it is completely inappropriate to shift funding for public health - or funding for patient subsidies on the exchange - to cover the SGR fix. Congress must find another way to work this out that is not on the backs of our patients or our nation's already eroded public health system.

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