Friday, August 28, 2009

For the Sake of Our Health, Let’s Practice Prevention, Not Ideology--And Not Bean Counting

An ounce of prevention is worth a pound of cure, as Benjamin Franklin said.  One of the strangest debates around health care reform is over whether or not prevention saves money.   Of course it does.  

But George Orwell was right when he said, “To see what is front of one’s nose needs a constant struggle.”   So I’ll spell it out, for the benefit of skeptics, who come in two forms: ideologues and bean counters:

Keeping Americans healthier means we wouldn’t require as much medical care.  Without as much medical care, we don’t spend as much on medical care. 

On top of that, being healthier means we’re more productive, and we need to be a more productive to turn the economy around and compete with the rest of the world.  Yes, such prevention might require an upfront investment here and there, but it’s worth it, even if we don’t see the benefit right away. As the great French economist Fredric Bastiat observed, there’s a useful distinction to be made between “what is seen, and what is not seen.” As he wrote in 1848:

This difference is tremendous; for it almost always happens that when the immediate consequence is favorable, the later consequences are disastrous, and vice versa. Whence it follows that the bad economist pursues a small present good that will be followed by a great evil to come, while the good economist pursues a great good to come, at the risk of a small present evil.

Interestingly enough, Bastiat illustrated his point with an analogy from... preventive health:

The same thing, of course, is true of health and morals. Often, the sweeter the first fruit of a habit, the more bitter are its later fruits: for example, debauchery, sloth, prodigality. When a man is impressed by the effect that is seen and has not yet learned to discern the effects that are not seen, he indulges in deplorable habits, not only through natural inclination, but deliberately.

Bastiat rightfully belongs in the pantheon of free-market economists, and yet his wisdom derives from that most marvelous of tutors--common sense.

And yet in a way that Orwell would have recognized, if not appreciated, some ideologues have staked out positions that put them crosswise of the age-old wisdom of prevention--wisdom, of course, updated for our technological time. An ideological case in point is one Zachary David Skaggs, health policy analyst for the right-leaning Liberty Coalition, who whose article in The Washington Examineris boldly entitled, “Preventive medicine doesn’t work.” 

Wow! There’s a keeper: “preventive medicine doesn’t work.” One might be tempted to think that Skaggs was a victim of an oversimplifying headline writer, but sure enough, as one reads the article Skaggs genuinely seems to think that “over-diagnosis” is a greater danger than under-detection. And, he says, “hundreds of studies” back him up. To which we might begin by asking, “Danger to whom?” And then note that “hundreds of studies” proved that man couldn’t fly--until he did. Perseverance is a virtue in medicine, just as it is in engineering. The danger that seems to animate Skaggs is the “danger” that we might spend too much money, trying to be safe, rather than sorry. (Interestingly enough, Skaggs’ argument overlaps with the argument made by some on the left as well, including Shannon Brownlee of the New America Foundation, author of Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer.)

It’s right and proper to scrutinize all tests and procedures for overuse, as well as outright theft and fraud, and improvements can always be found. But in medicine, small is not beautiful. The cost of underconsumption of health care is obviously vastly greater than the cost overconsumption. If you overconsume, you most likely will have spent too much. But if you underconsume, you most likely will get sick and die. A simple Pap smear--a piece of preventive medicine that’s been continuously improved over the last 80 years--can cut deaths from cervical cancer by as much as 99 percent. And today, having passed over the "cost hump" on Pap smears, women live longer, and we spend less on cervical cancer. That’s a true win-win. Of course, the bean-counters don’t see it that way, but I am getting ahead of myself.

Sticking for the moment with Skaggs and his right-leaning neo-Luddism, we might note that the list of life-saving preventive medicines goes on and on. But it always helps to know what the problem is. Quick! Is that a migraine headache, or a cerebral aneurysm? Is that a stomach ache, or a burst appendix? Is that heartburn, or a heart attack? And, oh, by the way, is that rodent over there a harmless omnivore, or is it carrying bubonic plague? We can quickly see that a key difference between First World countries and Third World countries is that the former suffer from the mild maladies of health care overconsumption, while the latter suffer from the deadly epidemics associated with health care underconsumption.

And did I mention swine flu? The work of the Centers for Disease Control and the Public Health Service is expensive, and it might not even succeed in staving off an epidemic. But in light of estimates that the H1N1 virus could hospitalize up to 1.8 million Americans and kill 90,000--and with memories of past influenza epidemics that killed tens of millions still lingering in our historical consciousness--how many Americans want Uncle Sam to give up work on a vaccine? Or to stop spending money on related public health measures?

Carelessness about key health questions takes you to a dead end. Not just intellectually, but literally. And while yes, it might seem cheaper, according to a certain ruthlessly cold-hearted calculus, to see some people die off and not run up health care bills, that calculus is usually yet another example of Bastiat’s seen vs. unseen dichotomy. Most people with serious illnesses end up in the hospital sooner or later, and that costs money. And yet the even larger loss is not only to the individual and his family, but to society, in terms of lost income and productivity. Conservatives are right to worry about the Nanny State, but they should also consider the cost of the ICU State. And the Morgue State.

But there’s another belief system, too, working against the idea of prevention. That’s the faith in bean-counting as an end in itself--in defiance, once again, of common sense. One bastion of bean-counting is the Congressional Budget Office (CBO) , which has relentlessly insisted that prevention cannot be “scored” as a savings in any health care plan.  

The CBO, it seems, cannot "do the math" to figure out how prevention saves money over time. Okay, fair enough, the CBO can't know everything. But in the meantime, just because the CBO doesn’t know how to account for something, that doesn’t make the thing not exist. The physical world existed before we had numbers to enumerate it.

We all know there are limits to CBO’s sensibilities.  For instance, as Louis Woodhill has pointed out, under the current CBO rules of “static analysis,” if we proposed a huge tax on lima beans--say, 12 trillion percent--CBO would score it to show we could balance the federal budget.  Of course, that doesn’t mean it would, since in reality people would stop eating lima beans because the new tax would mean that the cost has gone through the roof, all the way to Pluto.
The proposals in the current health reform bills, in the House, and  in the Senate, aren’t talking about screening every American for obscure diseases featured only on episodes of "House." They’re focused on fighting health problems that are rampant in America–such as obesity and smoking –with proven, evidence-based disease prevention programs.  And since nobody seriously argues that more smoking and more obesity would be good for our nation’s health, or our overall well-being, it’s worth combating those public-health problems.  But with all the hand-wringing over the details of paying for health care, we’ve lost sight of the fact that any good effort to reform health reform care should actually try to improve the health of Americans.  

The research shows that starting early--like way before someone has advanced diabetes or late-stage lung cancer--is critical not only to the survival of the patient, but also to the biggest monetary savings. Targeting these problems means helping people quit smoking, eat more nutritiously, and get more exercise, which often don’t even involve going to the doctor’s office.  The New York Academy of Medicine has identified dozens of low-cost programs around the country that have shown real results in reducing smoking rates, limiting diabetes, improving nutrition, and increasing exercise, which then in turn reduce rates of disease.

Such wellness in turn reduces health spending.  These results quickly add up:  A recent studyby the Trust for America’s Health shows that an investment of $1 in evidence-based disease prevention programs in communities can lead to $5.60 in health care cost savings.  No doubt those calculations can be disputed here and there, but the intuitive truth of prevention--going back way before Ben Franklin--is so obvious that no amount of number-crunching can make the obvious gains disappear entirely. It’s simply cheaper to have a lumpectomy than a radical mastectomy.

Speaking of lima beans, no one’s going to make you eat them.  There are people who worry that talk of prevention is just an attempt by government to control what we eat or to force us to exercise.  And while there are some in the public-health world who would love to impose "fat taxes," or even go further, toward fat-prohibition and other kinds of draconian health mandates. Those are fights for the future. But in the meantime, we are free to be more healthy--or not.

Just last week, a new study from Finland found that men who jogged or exercised fairly intensely for at least 30 minutes a day had a 50 percent reduction in their risk of dying prematurely from cancer. Sounds like a good deal.

As Washington debates the minutiae of health care dollars and cents, we’re missing what’s clearly common sense.  Better health is a good thing; it would be worth investing in even if it didn’t save money.  But it’s clear that lots of prevention efforts have the added bonus that they do save money.  And thus the double bonus: Americans would be more productive and in better shape, physically and economically, to compete with the rest of the world.  


  1. Same reason industrialist Henry Kaiser started Kaiser Permanente. When he was building the Grand Coulee Dam he established on-site clinics to provide medical care and preventative medicine to the construction workers in order to keep productivity high.

    The concept was so successful he implemented on-site medical care at his Richmond Shipyards in Oakland, CA where he built liberty ships and expanded the concept to include everything from exam rooms, pharmacy, labs, radiology and complete hospital care all on one site in a one-stop shop arrangement.

    Today we know this as group-model managed care.

    It is the solution.

    John Breheny

  2. If all of us rednecks quit smoking, who will pay for all those state and federal programs our cigarette taxes are currently supporting? - jh

  3. great post... first time at this blog, will be returning often!

  4. Zachary Skaggs here. Honored to have your input on my Examiner op-ed, Jim. I've found your commentary (on Fox News and to be illuminating and astute. Of course, I think you're wrong this time. :) Couple things:

    Good pick up on Brownlee. I am largely in agreement with her analysis, if not her policy recommendations. "Preventive Medicine Doesn't Work" also wasn't my original title, though I largely stand by it. On the to the substance...

    You point out that a simple pap smear will prevent cervical cancer deaths by as much as 99%. I am in agreement with you on the effectiveness of pap smears, as well as other forms of screening, such as visual examination for skin cancer. But a whole lot of preventive medicine is wasteful and results in subjecting people to procedures destructive to their health. Thus I'm not only arguing that such screenings and the interventions that follow are expensive and needless; I also argue that they make people less healthy than they otherwise would be.

    Take PSA screening for prostate cancer. The most recent U.S.-based large, randomized trial to examine the effectiveness of PSA screening, the PLCO, followed 77,000 people and found no mortality benefit for the yearly-PSA group versus the group who did not receive screenings. A large British study, the ERSPC, found a 20% reduction in mortality in the PSA-tested group, but at a significant cost. For every life saved due to early detection via PSA test, 50 patients were subjected to pointless treatment, meaning biopsy, radiation therapy, anti-androgen hormonal therapy, and radical prostatectomy. There's a reason Bob Dole hawks not only PSA "early detection" but Viagra.

    Or consider mammograms, the holy grail of the preventive medicine camp. A recent study showed that since (roughly) their introduction there has been a 40% increase in breast cancer diagnosis, including a near-doubling of early-stage breast cancer diagnosis, but a decline in incidence of only 10% for late-stage breast cancer. Were the early detection, early treatment mantra true, we should see, along with greater detection of early-stage cancers, a corresponding decline in late-stage cancers. Rather, we just see a bunch of new diagnosis with little effect on mortality.

    The likely reason for this strange discrepancy is that we are detecting and treating mostly benign, slow-growing cancer and missing the fast-acting, fatal varieties. Prostate cancer, for instance, is present in over half of 65-year-olds, but will only kill perhaps 5% of them (they'll succumb to something else first; the 5 year survival rate following prostate cancer diagnosis is 99%). Almost everyone over the age of 80 has prostate cancer.

    I'm not sure I understand the relevance of your comparison of the sort of maladies suffered in the third world versus the first.

    People should be allowed to determine for themselves whether they think the rewards outweigh the risks of screening and other forms of preventive medicine. But I'm no luddite for pointing out that, once one looks at the numbers, much of so-called preventive medicine is merely a foot-in-the door for a series of wasteful and health-harmful interventions.

    I look forward to reading the rest of your blog. To be sure, I didn't know until this vanity google search that you were involved with the health care issue.

    Zachary Skaggs