America’s Healthcare System – Part 7

Shifting Our Focus from Treatment to Prevention

This is the seventh essay in Civic Way’s series on the US healthcare sector. In this essay, we focus on one of healthcare’s major flaws—inadequate prevention (and public health). The author, Bob Melville, is the founder of Civic Way, a nonprofit dedicated to good government, and a management consultant with over 45 years of experience improving public agencies.

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Highlights:

• By neglecting proven prevention strategies, like community-based public health and primary care programs, we increase healthcare costs and put our long-term physical and mental health at risk

• The real tragedy is that many of the leading causes of death in the US could be prevented or at least mitigated long before they kill our fellow Americans

• Chronic disease, which is ravaging our nation, exemplifies the need for more prevention, partly because it is so pervasive, partly because it is something we can tackle as individuals

• Adopting a prevention first mindset—investing in public health and a comprehensive community-based primary care system—would revolutionize our healthcare system, and revitalize our nation

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Introduction

Every year, Americans pay twice as much for healthcare as citizens of other developed nations. Given how much we spend, it would be reasonable to expect far better health outcomes than other nations. Sadly, our outcomes are actually worse, and the gap between the US and our peers is worsening by the year.

There are many reasons for this phenomenon. Too little prevention (and public health capacity). Uneven care access and quality. Fragmented healthcare resources. An ill-conceived healthcare financing (insurance) system. Profit-driven (instead of people-driven) innovation. Antiquated administrative systems.

In this essay, we focus on the first of these causal factors—inadequate prevention. In future essays, we will outline the other major causal factors, and some bold—and not so bold—ideas for fixing those flaws.

Treating the Preventable

Perhaps the US healthcare system’s single biggest flaw is its indifference to prevention. Instead of investing in prevention, we spend lavishly on treatment. Since our national resources are finite, spending too much on treatment cheats prevention of desperately needed resources.

The inevitable result? We spend far more on healthcare than we should, and for subpar outcomes. By neglecting proven prevention strategies, like community-based public health and primary care programs, we increase healthcare costs and put our long-term physical and mental health at risk.

The Causes of Death

The facts are clear, and they have been known for some time.

Our national longevity suffers by comparison to other affluent nations (see last essay). About one-half of US deaths are due to homicides, suicides, accidents, cancer and chronic disease.

The tragedy is that many of these causes can be confronted and mitigated long before they result in death. Homicides can be reduced by gun control and safety measures. Traffic accidents can be—and have been—reduced by evidence-based highway and auto safety measures. Cancer can be at least partially prevented by reducing toxins in our air and water. Such measures usually require significant public investment.

Perhaps no cause of death illustrates the potential of prevention more than chronic disease. Fortunately, it is over this causal factor that individuals have the most control.

The Curse of Chronic Disease

Chronic diseases—diabetes, circulatory conditions, chronic obstructive pulmonary diseases (COPD), asthma and congestive heart failure—are ravaging the American healthcare system. Chronic diseases account for at least 80 percent of hospital admissions, 90 percent of prescription drugs and 75 percent of physician visits.

While many chronic conditions surface in young adulthood, their long-term impacts are often preventable or at least controllable. Over 20 percent of US adults aged 18 to 39 have high blood pressure. Nearly 25 percent of US adults aged 18 to 44 have prediabetes. Addressing these conditions promptly could prevent serious diseases, if not premature fatalities.

The US has more hospital admissions for preventable chronic diseases than comparable nations. These admissions could be significantly reduced if we would be willing to shift more healthcare dollars from treatment to prevention. However, with so few resources allocated to prevention—like public health and primary care—chronic disease will likely remain the dominant driver of our staggering healthcare costs.

Reducing Chronic Disease

How do we know that so much chronic disease is preventable?

There is growing evidence that chronic disease—or its severity—is often a product of nonmedical factors, what many experts call the social determinants of health. What are these factors? Some are economic like work- and debt-related stress. Some are environmental like housing, infrastructure, pollution and safety. Other critical factors include nutrition, lifestyle (including exercise), community and education.

All of these factors merit aggressive public responses, but one factor deserves special focus—nutrition. Poor nutrition, whether from a poor diet or food insecurity, is a compelling predictor of poor health. About one-half of all Americans suffer from at least one diet-related chronic disease. And food deficits hit disadvantaged Americans particularly hard (Medicaid is no help). Conversely, a healthy diet can prevent or delay chronic illnesses, reduce the need for medication (e.g., insulin) and facilitate treatment and healing.

Our Short-Sighted Response

The correlation between social determinants (like nutrition) and our health is well known. However, seeing the link is not the same as capitalizing on its knowledge. The US continues to spend significantly less on disease prevention and social services—and far more on the treatment of chronic conditions—than other industrialized nations. This approach is especially evident in two areas—public health and primary care.

The US has long discounted its public health programs (see public health essay). We scrimp on prevention. We isolate public health from healthcare. We fail to leverage complementary public services like housing, childcare and nutrition. We leave primary care providers to navigate nonmedical issues with inadequate resources.

We treat primary care with surprising indifference. For instance, it is estimated that nearly half of Americans in their twenties don’t have a primary care physician. Instead of using primary care providers to spot conditions before they require serious intervention, many of us wait until the serious condition arises, and then rush to the nearest specialist. The ensuring treatment is likely to cost far more than any preventive measures.

The Opportunity

Adopting a prevention first mindset would revolutionize the US’ healthcare system.

Building an adequate public health system would dramatically reduce disease, fatalities and healthcare costs. Strengthening our ability to track community health threats would significantly protect individuals from those threats. Amplifying our state and local outreach efforts, especially those that promote wellness programs, would encourage the widespread acceptance of healthy lifestyles.

Investing in adequate community-based primary care would help us realize its full potential. The primary care practice is our portal to longevity. It is where we are seen as an individual, not a generic patient. Where we receive tests and check-ups that reveal health issues before they consume us. Where we are prescribed drugs that work. Perhaps most importantly, it is where we assume more responsibility for our own care.

Ultimately, the impact on health outcomes will be profound, and irrevocable. Fewer chronic diseases, hospital admissions and deaths. Fewer emergency department visits, lower treatment costs, more healthcare resources and better access for the historically under-served.