The championing of prevention as a matter of economic prudence echoes arguments during the fight for passage of the Patient Protection and Affordable Care Act that the measure would lower long-term healthcare costs by improving the populace's health. That would be achieved, proponents said, by expanding insurance coverage (ensuring more people get care before they have acute medical needs) and with an array of other provisions.
“These savings can be achieved by standardizing quality care, incentivizing efficiency, investing in proven ways not only to treat illness but to prevent them,” President Barack Obama said in a May 11, 2009 speech.
In addition to specific preventive-care initiatives (See chart), the law eliminates out-of-pocket expenses for preventive-care visits for Medicare beneficiaries and requires that private insurers do the same.
On April 13, the House of Representatives voted to repeal the law's Prevention and Public Health Fund, which authorizes the HHS secretary to distribute $17.75 billion from 2012-21. Democrats responded that Republicans were acting cynically to cut spending on prevention while claiming fiscal responsibility as their top priority.
“For decades our healthcare system has been designed to treat patients once they're sick,” Rep. Anna Eshoo (D-Calif.) said in an April House floor speech. “This is inefficient and costly. The Prevention and Public Health Fund included in healthcare reform is finally starting to change this backward system and invest in efforts to keep people healthy.”
It's a simple and powerful argument. And for some types of prevention initiatives, such claims are indisputably true.
The wide range of activities encompassed under “prevention” includes many clinical services, such as vaccinations or prescription medications that help people quit smoking and thus prevent disease. Some of these primary prevention programs are relatively inexpensive and can eliminate the future cost of treating expensive diseases, according to recent studies.
Low-cost efforts such as smoking cessation screening, alcohol abuse screening and daily aspirin use among groups at-risk for heart attacks could reduce annual healthcare spending by $3.7 billion, according to a September study published in Health Affairs by Michael Macioseka, research investigator at the HealthPartners Research Foundation, and colleagues.
But savings quickly turn into costs after factoring in most other types of prevention efforts. For instance, secondary preventive services that aim to catch disease early and treat it relatively cheaply include mammograms.
In the best case scenarios, the tests find and allow early and successful treatment of breast cancer. But that requires undertaking populationwide disease-detection tests. Such testing on a massive scale is hugely expensive, as noted by the U.S. Preventive Services Task Force in November 2009, when it revised its breast cancer screening recommendations to suggest women begin mammograms at 50 instead of 40.
Large-scale testing also results in many inaccurate findings, the task force noted, which adds more expenses in unnecessary medical and surgical treatments. Or they find conditions that do not need treatment, such as prostate cancer in older men that progresses so slowly it would never impact their health.
A third category of prevention, tertiary programs, aims to slow the progression of a diagnosed disease. Those efforts, including lowering the cholesterol of people with heart disease, are among some of the most expensive prevention programs when applied populationwide. For example, prescribing statins for people with elevated cholesterol levels to prevent heart attacks is effective, researchers say, but also costs hundreds of thousands of dollars for each year of life saved.
A 2000 study in the Annals of Internal Medicine concluded that putting men ages 45-54 at low risk for heart disease on statins would cost about $400,000 for each life year gained.
The annual cost of such prevention would reach trillions of dollars when multiplied across the relevant members of the group of 81 million American adults estimated to have some type of cardiovascular disease and dwarf the $71 billion inpatient hospital cost for cardiovascular disease in 2006, as estimated by research published in Circulation, the journal of the American Heart Association.
Such findings reflect what appears to be a broad conclusion of clinical research: Prevention adds to healthcare costs. The authors of a Feb. 14, 2008 New England Journal of Medicine compiled 599 published studies on the cost of prevention and found it increased medical spending in more than 80% of instances in which it was used.
“The short answer is that prevention is generally not a cost saver, at least in the near term, although there may be a few specific exceptions,” said Paul Van de Water, a senior fellow at the generally liberal Center on Budget and Policy Priorities.
But advocates of prevention argue that such figures vastly underestimate the cost-benefit of prevention efforts because they do not include all of the indirect costs and benefits involved. For instance, in 2009 U.S. heart disease cost $475 billion, which included the cost of treatment, medications and lost productivity, according to Circulation research.
“We hold prevention to a very different standard than the rest of healthcare,” Dr. Georges Benjamin, executive director of the American Public Health Association. “We need to begin looking at the real savings it provides to the entire system.”