Conventional wisdom about healthcare reform rests on a big lie. Most major proposals for healthcare reform depend for financing in part on the purported savings from preventive care. The problem is that preventive care does not save money.
No less an authority than the Congressional Budget Office has pointed out that both the scientific and the financial literature indicate that preventive care is at best a break-even proposition, and may actually cost money. Members of Congress and proponents of healthcare reform have expressed shock at the CBO’s findings, but it’s not really surprising when you consider what preventive care is, what it can do, and what it costs.
A fundamental lay assumption about health is that all people could be healthy if we simply tried hard enough. That’s a corollary to the American fantasy that we have far more control over our health than we actually do. While personal habits and the environment do have an impact, health is largely beyond our control, depending as it does on genetic factors, natural pathogens like bacteria and viruses, and the inevitable wear and tear of aging. In fact, most people, if they live long enough, are sure to get sick. Thus preventive healthcare, even at its most effective, can only postpone disease or turn fatal diseases into chronic diseases.
The benefits of preventive care to the individual are beyond dispute. It is obviously better to be healthy or at least healthier than to be sick. The benefits to society, on the other hand, must be balanced against the costs of preventive care, and, it turns out, preventive care costs quite a bit.
The CBO explains the different costs of preventive care:
The direct cost of the preventive service;
The cost of treating any adverse reactions to the preventive
service;
The cost of follow-up testing and treatment for patients with positive screening tests; and
The cost of treating unrelated diseases that occur because of an individual’s extended life span. (emphasis in the original)
These costs can vary widely depending on the specific type of preventive care. Consider Pap smears, the test for cervical cancer. Pap smears are relatively inexpensive and have no adverse reactions. However they have a high false positive rate (many more women have abnormal Pap smears than have cervical cancer and pre-cancer). Every woman with an abnormal Pap smear will need to have an intensive follow up exam with special instruments and biopsies of the cervix, but most won’t have the disease. Early cervical cancer is relatively easy to treat successfully, leading to many more years of productive life. Ultimately, of course, a woman cured of cervical cancer will go on to develop other medical problems that will cost money. On balance, though, the costs of prevention are small, and the benefits are large.
On the other hand, diseases like AIDS have a very different cost benefit ratio. HIV testing for the virus is relatively inexpensive, and the follow up testing is not expensive, either. However, the treatment is extraordinarily expensive and it does not cure the disease. It can cost upwards of $10,000 a month for anti-retroviral medication. And the medication merely turns a disease that is fatal in the short term, to a chronic disease that may last years and is often fatal in the long term. The benefits to the patient and his family are, of course, incalculable, but the financial costs are massive.
That does not mean that we should stop HIV testing or other extremely expensive forms of preventive care. We are ethically mandated to provide testing and treatment, even though it costs a considerable amount. It does mean, though, that we must shed out delusions that the “cost savings” of preventive medicine can finance healthcare reform.
Associated Press writer Carla K. Johnson reports:
Legislation pushed by Senate Democrats mentions “prevention” repeatedly. The Senate panel heading up health reform also calls for more research on prevention…
President Barack Obama as recently as April said investing in prevention “will save huge amounts of money in the long term.” And it has become almost an article of faith among Republicans, Democrats and business leaders that prevention reduces health care costs.
But the Congressional Budget Office last week issued a statement on health care overhaul that dismissed the notion that prevention saves money. Prevention “would have clearer positive effects on health than on the federal budget,” the CBO said…
[R]esearcher Peter Neumann of Tufts Medical Center said counting on disease prevention to save money “promises painless solutions to our health cost problems. I don’t think they’re going to be painless and they have to be done.”
Healthcare reform is going to involve extremely difficult financial choices, and the sooner we stop pretending that preventive medicine will minimize the need for such financial choices, the better off we will be.
