This past year’s health discussion has been remarkable for the narrow range of ideas and opinions that have floated down to the man on the street. Journalists have sought out the same organizations and sources for their stories, offering up what has become the conventional wisdom for reform. To bring more voices into the conversation, our series, Excluded Voices, will intermittently feature health care experts who aren’t on the media’s A-list of sources. This is the fifth entry in the series, which is archived here.) We want to offer journalists more options for their stories and encourage a deeper conversation. To that end, we’ve asked the experts featured in each post to respond to questions from Campaign Desk readers.
Ask any pol or business exec how to lower the cost of medical care, and most will reply “preventive care.” Average Americans apparently agree. A new poll by the Robert Wood Johnson Foundation and Trust for America’s Health found that more than three quarters of Americans believe funding for preventive care should increase. The reasoning goes like this: if you catch illness early, it saves treatment costs in the long run. What can be more straightforward? Problem is, there’s oodles of evidence that prevention costs more than it saves.
Few in the media have cast a skeptical eye on preventive care as a magic wand that will make expensive medical care disappear. More should. To help those wanting to give audiences the complete story on preventive care, Campaign Desk talked to Rutgers research professor Louise Russell, whose work is well known in academic circles but less well known in the popular press.
Trudy Lieberman: What exactly do we mean by preventive care?
Louise Russell: Primary prevention, such as vaccines, completely prevents the disease. Secondary prevention either treats a risk factor for disease or detects disease in an early stage, when it can be treated more effectively. Blood pressure medicines and statins to lower cholesterol and pap smears are good examples. Tertiary prevention means someone already has a disease but wants to prevent further consequences. An example is treating diabetes by controlling blood sugar and blood pressure, and conducting eye exams and foot checks to prevent blindness and amputations.
TL: Do people confuse risk factors with disease?
LR: Sometimes. People often think that if they have high blood pressure or high cholesterol, they have a disease—when, in fact, they are being treated to reduce the risk of diseases associated with those conditions.
TL: Why does prevention seem like such an easy answer to the cost problem?
LR: It just seems so logical, since if you prevent the disease, you avoid the cost of treating it. And people tend to focus on the cost per person, which can look low, not on the aggregate costs of mounting a preventive intervention.
TL: Can you amplify that a bit more?
LR: In order to get the benefit of prevention, you have to treat lots of people, often for a long time, and the cost of that treatment adds up. The cost to treat one person may look small, but the cost for everyone is large. And prevention isn’t perfect. Some people will get the disease in spite of preventive care. Others would not get it even without preventive care. The upshot is many people incur costs for prevention, but only some experience savings.
TL: Can you still go further?
LR: For example, you may have to give prevention, say blood pressure medication, to 100 or 1000 people for years to prevent one death from stroke or heart disease. All of those people incur the costs of prevention, but savings accrue only for the one whose death is prevented. That’s why, most of the time, prevention does not produce savings.
TL: Then it is not a panacea, right?
LR: It’s touted as one, but it is not. In fact, prevention has contributed to our rising medical costs.
TL: Can you give an example?
LR: Statins are widely used for millions of people. They do not save money and are enormously expensive, costing thousands of dollars—in some cases hundreds of thousands of dollars—for every year of life that they save.
TL: Does that mean we shouldn’t use them?
LR: Not necessarily. It is perfectly legitimate to decide that the better health gained from statins is worth the expense. But it does mean that we need to realize that prevention is not going to help reduce the growth of medical spending.
TL: Some people say, “Yes, but if one life is saved, it’s worth it.” Is there another way to think about the individual vs. the population question?