For more than a generation after antibiotics became commonplace, the tiny round bacterium known as the pneumococcus remained a pitiless reaper of the elderly. It would suddenly show up in their lungs, and within hours, suffocate its victim. Then in 1978, the Food and Drug Administration approved a vaccine. But the law prohibited Medicare from paying for it -- and not because the vaccine was unsafe or ineffective. It was because Medicare specifically excluded coverage for preventive care.
Congress moved in 1980 to cover the vaccine, making its first-ever exception to Medicare's policy of nonpayment for preventive services. You'd think broad coverage of care that averts illness would be a no-brainer. Of course Medicare should cover prevention! So should health reform! Preventive care saves lives and money! What's not to love?
Health reformers, though, will have a hard time selling this story to Congress. The economics just don't add up. Congress' Pay As You Go (PAYGO) budget rules keep bills from coming out of committee unless they're budget-neutral over 10 years -- or better yet, a net savings. And it turns out that letting pneumococci kill Grandma would "save" money. The vaccine itself costs less than what Medicare would have to pay to treat pneumonia and other illnesses that immunization would prevent. But the problem is that it lets Grandma live longer. She busts the budget by going to the doctor later in life, for pricey care she wouldn't need if she were dead.
On the political stump, the standard story is that prevention saves health-care dollars. But the standard story is wrong. If we're to get better at averting illness, we're going to have to spend more. The Tufts Medical Center Cost-Effectiveness Analysis project tracks published data on the costs and benefits of thousands of tests and treatments, including 279 preventive measures. Fewer than 20 percent of these measures actually save money, the Tufts group recently reported in The New England Journal of Medicine. The rest raise medical spending, and that's not even counting the extra costs patients incur down the line, for illnesses they could have avoided by dying.
Several years ago, the Congressional Budget Office declared that "to the extent that a drug benefit helps people live longer, they may consume more health care over their remaining lifetime than they would have without the benefit." This calculus forced Congress to downsize Medicare drug coverage. If you push this line of thinking to its endpoint, the cheapest heath care is no care at all. A Swiftian proposal for euthanizing infants is only somewhat farfetched: After all, that way, they'll never get sick. In the real world, where health spending is supposed to improve health, most preventive measures are worth paying for. The question, after all, is not just spending but value. More than 80 percent of the 279 preventive steps tracked by the Tufts group add to America's health-care bill. But most of these deliver good value for the money.
Researchers tend to measure the value of treatment through something called Quality Adjusted Life Years. This method, based on studies of the costs consumers and workers incur to avoid death, prices life at $5 million to $10 million. The respected health economist David Cutler roughly translates these figures into a cut-off value of $100,000 per year of life saved. (Some say this number should be adjusted downward for people who live with pain or disability.) Economics earns its moniker, "the dismal science," through calculations of this sort. But since trade-offs between scarce resources -- even life-prolonging resources -- are inevitable, it's useful to create such morbid formulas.
Of the preventive measures that raise medical spending, more than three-quarters "buy" longer life for less than $100,000 per year, according to the Tufts group. They save people at a price we should pay, but PAYGO isn't concerned with whether spending is "worth it" -- it still demands that Congress cut other programs or raise taxes to offset the cost.
So health reformers will need to make the case that prevention is "worth it" -- worth the spending cuts or tax hikes PAYGO will demand. There's an urgent need for a large-scale effort to measure the impact of preventive interventions on the length and quality of people's lives. Proponents of prevention should take a cue from conservatives, who have long demanded cost-benefit analysis of regulations that burden business. By attaching dollar values to benefits as well as costs, reformers can pressure politicians to take benefits more seriously. Many progressives eschew such studies because they put dollar values on life, but surely lives saved are better priced than ignored.
If advocates find that new spending isn't forthcoming, perhaps the smartest route would be to shift spending from wasteful interventions to preventive measures. It's often noted that more than a quarter of all Medicare spending occurs in the last year of life, suggesting that a lot of money is going toward heroic interventions with low chances for success. We must become more reluctant to pay for late-stage rescue technologies absent compelling proof that they work.
Cutting off access to widely used treatments -- methods that people believe in, even if the clinical evidence is questionable -- is sure to arouse ire. But there would be less political opposition to setting a high scientific bar for new rescue therapies. Even that would save money that could go toward preventive care.
Meanwhile, overwhelming evidence supports the conclusion that socioeconomic factors have a larger influence on our health than does medical care. Indeed, a prolonged and severe recession could do huge damage to Americans' health. Income and educational achievement correlate much more closely with health status than does medical spending. Paradoxically, we could improve the nation's health by rechanneling money from medical technology toward programs that boost Americans' economic possibilities.
Prevention, in sum, is being both oversold and undervalued as we approach large decisions about health-care reform. It won't slow the rise of medical spending. But it can do much to improve our health -- at a price that's worth paying.
