The Primacy of Prevention

The case for universal health-insurance coverage is becoming universally acknowledged. To make a real difference in health outcomes, cost, and system performance, we need to cover the whole person, with a full continuum of appropriate care, and ensure continuity over a person's entire life. Anything less will perpetuate inefficiencies and poorly coordinated coverage, which engender fragmented and poor-quality care. But universal coverage alone is not sufficient to reduce the remarkable 35-year difference in life expectancy across different classes of Americans. Universal coverage alone is also not likely to greatly improve the United States' ranking of 46th in life expectancy and 42nd in infant mortality among 192 nations. A high-performing national health-care system must also focus on the prevention of disease and promotion of optimal health for all its citizens.

Effective prevention strategies are not just about routine screening tests provided by doctors in offices or clinics. They are also about methodically addressing the factors that determine health and disease. The inconvenient truth is that many important health determinants -- including numerous risky behaviors and social environments that systematically expose people to toxic stress -- promote undesirable food choices, limit opportunities to exercise, and usually fail to respond to even the best prevention efforts dispensed by our personal physicians.

Over the past few decades, in particular since our last attempt at national health reform in the early 1990s, important new research has transformed our understanding of what determines health. We know much more about how particular diseases, such as heart disease, evolve over decades and how environmental influences align to channel long-term health outcomes. The policies developed to reform the health-care system, and the ways in which we judge the system's performance over the coming years, should incorporate these paradigmatic shifts in our knowledge about what triggers disease and determines health. Our policies need to encourage innovation in the organization, financing, and delivery of health services that exploit this new knowledge to catalyze genuine improvements in the nation's health.

What our country really needs is "Universal Coverage PLUS" -- universal coverage that can also address the social, behavioral, and environmental determinants of health. We need to bring prevention and health promotion from the fringe to the core of the health system. Such an approach would re-engineer the health system to promote the health of individuals over the long periods during which health problems develop. To this end, our specialty-dominated health-care system should be turned on its head, so that a new and more robust form of primary health care can emerge. Moreover, health-care funding needs to expand beyond paying for individual care. We will get much more bang for our health-care buck by making strategic investments that promote the health of specific populations and communities. A sensible place to inaugurate this Universal Care-PLUS approach is with kids. With universal coverage for all Americans as the foundation, additional systemic reforms that transform the way in which we prevent disease and promote optimal health among children and adolescents will be an important down payment on future health returns and serve as an important national pilot for an innovative and necessary new health system that has prevention and health promotion built into the DNA of its basic operating logic.

THE PROMISE AND LIMITATIONS OF UNIVERSAL COVERAGE

The central goal of health-care reform efforts for most of the last century has been universal coverage. If enacted, universal coverage could eventually improve health and decrease health-care cost by bringing everyone into the same system, encouraging ties to a medical home, reducing the use of inappropriate and costly emergency room visits, mitigating the inefficiencies of interrupted care caused by coverage problems, and providing effective preventive interventions like regular mammograms, PAP smears, and other cancer screenings. The international experience shows that universal coverage can ensure access to acute medical care when individuals become ill, chronic disease management for the growing number of people with disabling chronic health conditions, and many preventive services that can avert or postpone the onset of disease.

These same cross-national comparisons, however, strongly suggest that universal coverage alone is not sufficient to achieve our national health and health-care goals. Even countries that have had universal coverage in place for several decades still have significant health disparities associated with the socioeconomic, behavioral, and environmental determinants of health. The now-famous Whitehall studies of British civil servants, for example, revealed how relative social status has continued to play a major role in the prevalence and impact of a range of chronic diseases from cancer to heart disease, even though the entire British population is fully insured. Civil servants that were higher up the pecking order, had more control over their lives, were more able to use what the system had to offer, and were more sophisticated in optimizing their health.

Similar observations have been made in the United States. Imagining a short ride on the Washington, D.C., Metro as the foil, Sir Michael Marmot, the lead investigator for the Whitehall studies, illustrated the impact of social status on health in the U.S. Each mile traveled on the Metro from the downtown Union Station to the suburbs of Bethesda, Maryland, Marmot showed, is associated with a 1.5-year gain in life expectancy. All told, there is a 20-year divergence in life expectancy between poor blacks at one end of the trip and affluent whites at the other.

Seizing upon the emerging epidemiologic research on the disparate causes of disease, many nations with universal coverage -- including Sweden, the United Kingdom, Netherlands, Denmark, and France -- are expanding preventive health interventions well beyond just medical care and insurance. These cross-sector policies attempt to coordinate the efforts of multiple government agencies and nongovernmental organizations to create physical and social environments that make it easier for individuals to adopt healthier behaviors. In addition, using tools known as "health impact assessments" these nations are now prospectively evaluating the short- and long-term health effects of proposed major transportation, industrial, and urban policy changes. The new National Institute for Health and Clinical Excellence in the UK is not only monitoring health-care system performance and informing standardized evidence-based medical care -- it is actively encouraging major population-based efforts to promote health across the life span.

THE NEW SCIENCE OF HEALTH DEVELOPMENT

The demographic and scientific basis for embracing this enhanced approach to universal coverage is increasingly compelling. Research on chronic disease and the effects of prevention indicates that nearly 60 percent of the chronic disease burden in the U.S. is accounted for by elevated blood pressure, high blood cholesterol, tobacco use, excessive alcohol consumption, low fruit and vegetable intake, and inadequate exercise. Almost four in 10 deaths are attributable to four behaviors that lie at the intersection of the social setting and individual choice: smoking, poor diet, drinking alcohol, and physical inactivity. Studies on the prevention of coronary heart disease (CHD) in the U.S., Finland, and Ireland have documented that 44 percent to 80 percent of the drop in CHD rates is due to systematic declines in major risk factors among the general population, like smoking, cholesterol, and lack of physical activity. Targeting specific high-risk populations with early interventions can also dramatically improve health outcomes. Overweight individuals with impaired glucose tolerance are more likely than others to become diabetic, resulting in devastating consequences for their quality of life and longevity and for the societal costs of medical care. Intensive lifestyle modification (exercise, diet) can reduce this risk of diabetes by 50 percent. In the throes of a national obesity epidemic, with diabetes rates skyrocketing, and given predictable rates of needless disability, premature death, and unsustainable costs, the logic for prevention could not be any more compelling.

Epidemiological investigations over the past 30 years have highlighted the significance of social and behavioral factors, rather than medical care alone, for improvements in life expectancy, onset and impact of disability, and overall health. A recent study by Robert Schoeni and his colleagues at the University of Michigan documents striking declines, between 1982 and 2005, in later-life disability. When these investigators examined the causes for these improvements, medical care had some but limited influence. Rather, half the decline was associated with boosts in educational attainment. Recognizing that formal education is an important prerequisite for optimal health and that educational achievement is in turn heavily shaped by the circumstances encountered during the first eight years of life, several nations have developed new comprehensive strategies to augment the health and welfare of children in their early years.

Over the past 15 years, the empirical study of life-course health development has begun to connect exposures and experiences early in life to health and disease trajectories later in life. Confirming what every nurturing grandmother believes intuitively about the benefits of encouraging her grandchildren to exercise regularly and eat their vegetables, a growing body of evidence demonstrates that adult risks for numerous common chronic diseases originate in the initial years of life. Exercise, diet, and behavioral changes adopted both in childhood and adulthood can diminish or postpone heart disease.

In recent years we have also learned that the timing of health threats to individuals can matter greatly. The ramifications of risk exposures tend to be magnified during especially sensitive periods in an individual's development. Research is helping to pinpoint how chaotic social environments, risky family situations, and toxic stress distort the formation of the immune, metabolic, and nervous systems. These changes can set in motion disease pathways early in life. How health trajectories develop, and how small health variations in children often are compounded to yield vast health differences in adults is exemplified by an increasingly common scenario. A child from a low-income family, with an overburdened single working parent and living in a dangerous neighborhood, watches a lot of television and exercises infrequently because it is not safe to play outside. He or she becomes overweight. Further, the social isolation and increased screen time breed reduced social competence. Combined with obesity, this diminished social competence produces even lower self esteem. As a teenager this individual has an increased likelihood of poor school performance, getting pregnant (if female), or dropping out, as well as having ongoing weight, social-competence, and other emotional issues. As an adult, this person is not only likely to be overweight, perhaps obese, but also may well develop high blood pressure, diabetes, and heart disease.

Early interventions that reduce risks and strengthen individual capacities can interrupt the chain of preventable events leading to this cascade of poor outcomes. The new information about what factors affect health, and when in the life span they have their impact, challenges the design or "operating logic" of the current health-care system. The existing system focuses primarily on diseases -- once symptoms are well established and treatments are costly. The system needs to include a logic of targeting investments and interventions earlier in the evolution and development of diseases. Improvements in the natural, social, and built environments in which individuals live, as well as enhancements in diet, exercise, and lifestyle, can have a profound effect on health trajectories, adult medical needs, and the overall costs of care. Recalibrating our health system to address this undeniable reality will require more than universal coverage.

UNIVERSAL COVERAGE-PLUS: EXPANSIVE PREVENTION

A health-care system with "Universal Coverage PLUS" would have a number of essential attributes, building on models already in place both here and abroad.

Moving Upstream: Preventing obesity, teenage mental-health problems, cardiovascular disease, diabetes, hypertension, and many common expensive medical conditions is not just about screening individuals for early signs that a disease is emerging. It involves identifying and promoting ways for the whole population to live healthier lives. The Kaiser Oakland Medical Center, for instance, reinforces its healthy-eating and weight-reduction programs by sponsoring local farmers' markets at its facilities and nearby communities. Smoking-cessation programs, putting physical education and sports programs back in schools, and creating incentives for individuals to utilize health clubs are all examples of efforts that could yield significant payoffs.

Upgrading & Putting Primary Health Care First: Ensuring effective prevention and health promotion within the health-care system requires strengthening primary health care. International evidence shows that countries with less specialization and well-developed primary health-care systems experience both better health outcomes and much lower costs. The U.S. system needs to make sure that a fully functioning primary health-care home is available to all as part of the covered-benefits package. This would not be your grandfather's primary care, with Marcus Welby diagnosing and treating your medical condition at his dining room table. It would be a robust, dynamic, and responsive primary health-care system. Linked to a multidisciplinary network of well-integrated primary health and wellness centers, it would serve as a point of first contact and provide comprehensive care, ensure continuity of treatment, prevent unnecessary emergency room trips, and serve as the connecting point to community-based prevention, health promotion, and wellness activities. Imagine overweight patients with hypertension whose primary health-care providers can coordinate care plans with their employers' stress-reduction programs and their YMCA's athletic and fitness center's weight control program.

Investing In Prevention, Not Just Paying for Care: Opponents of universal health care make the mistake of arguing that a greater emphasis on wellness, diet, and exercise can substitute for fundamental systemic reforms. But our current health-care system, with its constantly changing array of private health plans and continuous churning of coverage by employers, cannot support making long-term and sustained investments in health promotion. No single purchaser or provider has the incentive to take the long view -- from prenatal to late adulthood -- and make the necessary linkages and investments. Universal coverage would mitigate some of these problematic incentives, but explicit attention needs to be given to the long-term imperatives of prevention. Moving "upstream" and addressing the lifetime determinants of health, upgrading and improving primary health care, and giving due priority to prevention and health promotion strategies at the population level depends on having a universal-coverage financing system responsive to long-term performance and not just individual episodes of care. Here, too, other nations are taking the lead. Several countries are pooling public and private resources in national or regional "trusts," redirecting some of their patient-care dollars toward population-focused health improvement strategies with long-term timeframes.

STARTING WITH KIDS

A good place to start Universal Coverage-PLUS is with children and adolescents. They are at the most sensitive ages for determining lifelong health. Prevention and early investment are also consistent with recent economic research on human capital investment. A 2007 UNICEF report that compared the health and well-being of children and youths in 21 Organization for Economic Cooperation and Development nations placed the U.S. at the bottom or near the bottom on all measures. Most of the top-ranking nations in the report recognize that child health, education, and social welfare are inextricably linked, and that poor health begets poor education, which begets even poorer health. As with adults, the epidemiology of childhood is changing. Over the past century, childhood death and illness rates due to traditional medical conditions, such as infectious disease, have fallen dramatically, but differences in health between the best-off and worst-off children are escalating, the population of children with chronic conditions is swelling, and a growing number of children have mental, behavioral, and developmental problems. Effective intervention strategies, however, are already in the offing.

What might we learn from other countries as we build Universal Coverage-PLUS for kids? Until recently, child poverty rates, and other indicators of health and well-being, were quite comparable in Britain and the U.S. The respective percentages of children from immigrant families are also comparable. However, Britain has recently made impressive gains. The reforms in Britain's services for young children have their origins in the Black Report, a study conducted in the 1970s to determine why health inequalities persisted despite 30 years of the National Health Service. The report's recommendations underscored the importance of improving the material living conditions of the poorest groups, especially children. Largely ignored during the Thatcher years, the report's theme was seized by New Labour, when Tony Blair and Gordon Brown arrived on Downing Street in 1997 with an ambitious commitment to end child poverty in 20 years.

Several major policy reforms -- including Every Child Matters (2003), The Children's Act (2004), and the National Service Framework for Children, Young People, and Maternity Services -- laid the ground for integrating services for children into transformed universal systems of care. The reforms overcame the last vestiges of the "Elizabethan Poor Laws" mentality, offering high-quality services for all children without waiting for them or their families to fail. "Sure Start" is for the youngest children. Established originally in some of England's poorest areas, the program delivers integrated family support, health promotion, and early learning and play experiences for children under the age of 4. Each Sure Start area is relatively small, targeting around 800 children. Begun with 250 programs, Sure Start now has 2,500 centers with plans underway for the completion of 3,500 centers by 2010. Encouraged by the program's success, the Department for Children, School and Families recently declared that its intent is "to make this country the best place in the world for children and young people to grow up." But make no mistake -- this enhanced approach can work in large part because it is anchored in a lifelong universal system.

What should the United States do? We, too, should set national objectives for children's health and well-being with the goal of making U.S. children the healthiest in the world. That aspiration would require that all children have robust health-care coverage. Unlike most existing health insurance that covers children from the neck down, this coverage would address mental, developmental, behavioral, and dental conditions and risks. It would go beyond individual diagnostic, treatment, and rehabilitation services to emphasize prevention, early intervention, and general childhood health promotion services as well. Because some of the most effective prevention services children can receive are conferred in family, child-care, and school settings, Universal Coverage-PLUS would cover and encourage services in non-medical settings and promote information exchange among service providers.

Expanding coverage to all children should be linked with other reforms to bring the entire child health system into the 21st century. We need to launch our own version of England's Sure Start, putting in place a national 0-to-8 initiative designed to upgrade and link pediatric primary care, child care, and preschools, and other supports for families with young children. Using new information technology, we could transform what has been a fragmented array of spotty services and supports into a high-performing early childhood health system. To ensure performance and to measure health outcomes, we would institute a national monitoring system, which would augment and integrate the fragmented array of existing data collection approaches. These upgrades and improvement would also require the consolidation and integration of many categorical health programs, spanning several federal departments and agencies. New incentives would also be necessary to stimulate innovations in the planning, coordination, and collaborative delivery of services at the state and local levels.

Starting with children, Coverage-PLUS could function as a national pilot project for the entire population. Improvements in health-care outcomes for kids would demonstrate the gains to be obtained from a more inclusive and transformational approach to health system design. The policy and institutional mechanisms developed to achieve these health enhancements would provide invaluable information for subsequent investments in prevention and population health, and the design of effective primary health-care systems -- and make the case for universal coverage irrefutable. After all, healthy kids eventually become healthy adults.

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