What’s At Stake Although the U.S. spends $2.2 trillion every year for health care - far more than any other nation - Americans are not as healthy as they could or should be.

For the first time, we are raising a generation of children who are sicker and who may die younger than their parents, in part because of spiraling obesity rates. Nearly a third of adults are also obese, and almost half live with at least one chronic disease, such as heart disease, stroke, diabetes or cancer.

Besides the toll in suffering and shortened life, chronic disease is a major driver of health-care costs. Almost 75 cents of every dollar is spent treating chronic conditions, many of which, such as type 2 diabetes and heart disease, might have been prevented or delayed.

Which is why giving all Americans access to medical care, while an important goal, will not rein in ballooning health care costs or transform the nation’s health by itself.

In a recent speech to the American Medical Association, President Barack Obama stressed the importance of addressing the root causes of rising expenditures.

“Five of the costliest illnesses and conditions - cancer, cardiovascular disease, diabetes, lung disease, and strokes - can be prevented,” he said. “And yet only a fraction of every health care dollar goes to prevention or public health.”

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In fact, there is broad consensus among lawmakers in both parties that it makes more sense to invest in keeping people healthy than in treating chronic and costly diseases after the fact.

“We must engage individuals, health care providers and health plans to adopt a new, proactive approach to health care that emphasizes preventing disorders, achieving early diagnosis, and wisely managing chronic conditions, so we reduce the burden of disease and spend health care dollars more effectively, Sen. Olympia Snowe, a Maine Republican wrote last March in Roll Call.

But transforming a system organized around disease treatment, to one that promotes health will require engagement by every sector of society, from schools and businesses to real-estate developers and health-care providers.

And that, in turn, will take leadership, community involvement and money.

“There are ways to spend public dollars such that the scale tips towards ‘health’ and away from ‘sick,’ wrote Ezra Klein in The American Prospect. “But the ever-increasing portion of the budget we direct toward medical spending is squeezing them out.”

The Background Despite the $7,500 the U.S. spends per capita on health care each year, we rank 20th in life expectancy among major industrialized nations, and 27th in infant mortality.

Lack of access to health care is one factor. But experts contend that other reasons relate to how many of us live – what and how much we eat, whether we smoke or drink and the conditions in which we work, learn, and play.

Which is where prevention strategies come in.

There is broad consensus within the medical community about the effectiveness of a core set of preventive services, among them, screenings for high blood pressure, cholesterol, diabetes and certain cancers; childhood and adult immunizations, counseling services to help people stop smoking and the use of aspirin by people at high risk for cardiovascular disease.

But whether or not a person stays well in the first place has little to do with seeing a doctor. Some of the approaches that have had the most dramatic impact on health outcomes include raising taxes on cigarettes, limiting exposure to toxic substances, mandating seat-belt use, restricting alcohol sales to minors and building sidewalks and walking trails.

The Debate

“The cost per person, per year, can look low,” wrote Louise B. Russell, a cost-effectiveness expert at Rutgers University. “But when those costs are summed over all the people who receive the preventive intervention, and all the years they receive it, the total cost usually exceeds the treatment savings.”

The reason is that large numbers of people are often given disease screenings, for instance, not just the relatively small number who will eventually get sick. Moreover, savings are difficult to quantify in the five and 10-year budget windows that analysts use.

So for instance, the Congressional Budget Office concluded in December that a greater focus on prevention would at best generate modest cost reductions over 10 years, and might even increase costs.

Public health experts and advocates complain that budget analysts look almost exclusively at what happens in a doctor’s office. While screenings are important, they say, they are not the primary way we stay well.

A recent study by Trust for America’s Health focused on community initiatives and found that an investment of $10 per person per year in proven programs to increase physical activity, improve nutrition, and prevent or stop smoking could potentially save nearly $18 billion annually in 10 to 20 years.

Public health experts also argue that the question is whether prevention strategies provide good value, not whether they save money. Health reform should not just be about financing, they contend, but about making us healthier and improving our quality of life.

By large margins, the public shares that view. A recent survey, commissioned by Trust for America's Health and the Robert Wood Johnson Foundation, found that more than three-quarters of Americans support increasing funding for prevention programs. That support was shared by Republicans, Democrats and independents.

In fact, prevention was rated higher than all other health care proposals, including providing tax credits to small businesses and prohibiting insurers from denying coverage for preexisting conditions.

So what types of models are working?

State-funded tobacco control programs have proven track records of preventing kids from taking up smoking, and helping adults to quit. In the decade since California’s 1989 launch of an anti-tobacco program, for instance, adult smoking declined by 35 percent. One study concluded the program saved $86 billion in personal health care costs between 1989 and 2004.

Workplace wellness programs instituted by companies ranging from Intel to IBM are also achieving good results. Safeway, for instance, rewards employees who quit smoking, and who maintain healthy weight, blood pressure and cholesterol levels by discounting their health care premiums.

Some communities have also shown positive results by offering incentives to merchants to carry fresh fruits and vegetables.

In a report this spring, the Robert Wood Johnson Foundation’s Commission to Build a Healthier America, a nonpartisan group, recommended that the highest priority be given to strategies that promote children’s health, among them, banning junk food from schools, getting kids moving by requiring at least 30 minutes of exercise every day and creating public-private partnerships to open grocery stores in communities without access to healthy food.

While individuals are responsible for making healthful choices, the Commission said, society must also act to remove obstacles that get in the way such as the lack of a safe place to walk or the unavailability of fresh food.

To that end, it urged policymakers to incorporate health goals in every facet of public life, from housing and transportation to agriculture and education policies.

Where Things Stand in Washington Two of the bills under consideration in Congress, would dramatically boost prevention efforts by calling for the creation of a national prevention and wellness strategy and setting up trust funds to pay for it.

The Senate Heath, Education, Labor and Pensions Committee would require the president to set up an interagency council to set national health goals and coordinate development of prevention programs, with a budget of $10 billion a year. States and local governments and community groups would compete for grants, and employers would be eligible for incentives to set up wellness programs.

On the House side, the Tri-Committee bill directs the Health and Human Services Secretary to develop a national health strategy, and also sets up a fund to pay for it, starting with $4.6 billion next year and growing to $12.7 billion by 2019. That money would cover community and school-based prevention and wellness programs and nursing workforce development, among other things.

Those bills, as well as the proposal released by the Senate Finance Committee, would also waive cost-sharing for preventive services. The Senate Finance draft would establish a Chronic Care Management Innovation Center at the Centers for Medicare and Medicaid Services. Funded at $1 billion per year, the center would experiment with ways to encourage evidence-based, coordinated care. Reforms that improve quality and reduce costs could be expanded nationally without further legislation. The Senate Finance proposal would also require Medicare to set up a five-year initiative to provide incentives to beneficiaries who complete healthy lifestyle programs. It calls for reimbursing states for offering similar programs for those enrolled in Medicaid. Prevention Reading List

1. Beyond Health Care: New Directions to a Healthier America Recommendations from the RWJF Commission to Build a Healthier America, April 2009
2. Wellness Programs and Lifestyle Discrimination - The Legal Limits Michelle Mello and Meredith Rosenthal examine the extent to which employers and health plans can provide rewards and penalties for those who reduce health risks. New England Journal of Medicine, July 10, 2008.
3. Why Your Zip Code May Be May Be More Important to Your Health Than Your Genetic Code Dr. James Marks explains that where we live, work and play has a tremendous impact on our health. April 23, 2009.
4. Prevention for a Healthier America: Investments in Disease Prevention Yield Significant Savings, Stronger Communities Investments in disease prevention yield significant savings, stronger communities, RWJF report, July 2008
5. Partnership for Prevention Recommendations on Health Reform The group’s guidelines for health promotion and disease prevention in a reformed health system.
6. 2009 Almanac of Chronic Disease The Impact of Chronic Disease on U.S. Health and Prosperity: A Collection of Statistics and Commentary. Compiled by the Partnership to Fight Chronic Disease
7. Debating Prevention's Place in Healthcare Reform A draft Senate bill includes up to $10 billion for 'prevention and public health,' which could mean bike paths and farmers markets. Some lawmakers deride such measures as wasteful. Los Angeles Times, Aug. 3, 2009
8. Welfare-Care Reform: By Ezra Klein Fixing our health-care system will make us more economically secure, but it won't make us much healthier. American Prospect, June 18, 2009
9. How Safeway Is Cutting Health-Care Costs Safeway’s CEO Steven A. Burd argues that market-based solutions can cut health-care spending by 40 percent, describing the employee incentives he’s put in place at Safeway. Wall Street Journal, June 12, 2009
10. When All Else Fails: Forcing Workers Into Healthy Habits A look at how AmeriGas Propane Inc. gave its employees an ultimatum last year: get their medical checkups, or lose their health insurance. Wall Street Journal, July 8, 2009
11. Testimony of J. Randall MacDonald, Senior VP for Human Resources, IBM Corporation MacDonald testifies before the House Ways and Means Committee about how wellness programs have lowered costs and boosted employees’ health. April 29, 2009
12. A Closer Look at the Economic Argument for Disease Prevention Dr. Steven H. Woolf argues that preventive care should be assessed by whether it provides high value for its cost. JAMA, Feb. 4, 2009
13. Letter to Congress June 9, 2009 Several dozen groups, including unions and disease advocacy groups, laud health reform proposals that emphasize prevention, even while expressing concern that individuals not be penalized – either financially or by exclusion from services – if they are sick, overweight or engage in risky behaviors like smoking.
14. It's Not the Food We Can't Get. It's the Food We Can Blogger Ezra Klein talks about the challenge of changing people’s eating behavior. Washington Post, June 25, 2009.
15. The Myth of Prevention Dr. Abraham Verghese argues that while prevention is worthwhile, it will not save money - at least insofar as the screenings and other activities that happen in a doctor’s office. Wall Street Journal, June 20, 2009
16. Prevention Will Reduce Medical Costs: A Persistent Myth Louise B. Russell, a research professor at the Institute for Health, and an economics professor at Rutgers University, debunks the notion that prevention policies will lower health-care costs. HealthCare Cost Monitor, June 17, 2009
17. RWJF President Risa Lavizzo-Mourey Urges Congress to Make Disease Prevention a Priority Lavizzo-Mourey testifies before a Senate panel about need to shift the focus of health care from disease treatment “to preventing people from getting sick in the first place, investing in policies and programs that make it easier for all Americans to enjoy the benefits of good health." January 27, 2009
18. Poll: Prevention Is a Top Health Reform Priority For Americans A June poll, conducted by Greenberg Quinlan Rosner Research and Public Opinion Strategies, found that seven in 10 Americans believe that the level of funding for prevention should be increased, even if it will not save money.
19. Tobacco Regulation is a Step Toward Better Health Care RWJF President Risa Lavizzo-Mourey blogs about how the recent tobacco legislation provides a roadmap for other prevention efforts.