Mark Kleiman, for instance, writes that "[a]ir quality improvement, noise reduction, better parenting practices (which we can purchase publicly with nurse home visitation programs) and changes in the social forces influencing diet and exercise all probably have greater bang for the buck." Don't get me wrong, I'm fully for both preventive health measures and better public health policy. But I wouldn't get too excited over the insight that stripping lead paint from walls is a more efficient way to improve health outcomes than restructuring health care delivery. It's not always true, and, given the politics and emotional realities of the issue, it's not terrifically relevant.
First, the impacts of preventive medicine are often overstated. It's not that cleaning up the air or putting everyone on a gym regimen would greatly improve health -- but people don't follow gym regimens, and business doesn't let you clean air. Furthermore, not all interventions are created equal. Better parenting might be beneficial, but it's unlikely to be more effective -- either on economic or biological grounds -- than the use of statins, or hypertensive drugs, or daily tablets of aspirin. There are a lot of highly effective medical interventions which are very, very cheap. But our system is very poor at incentivizing their use.
Meanwhile, the reason doctors are constantly prescribing statins along with admonitions to exercise and eat better is because using public policy to change diet and exercise habits is really, really, hard, unless you're prepared to be very heavy-handed (i.e, outlawing trans fats in restaurants, setting portion limits, etc). Indeed, part of the problem with preventive health measures is that, rather often, they don't work very well. Like with traditional health care, some things really succeed (stripping lead out of gasoline, giving people antibiotics), and lots of things...don't. And that's to sidestep the weird reality that what drives health care politics is concern over money which, in fact, is quite rational: Folks don't want to go bankrupt, and smart politicians don't want the government to lose all space for spending on other priorities.
In any case, there is no tension between better preventive health measures and health reform -- a more integrated system would encourage preventive health, and every bill you know of that moves us towards universal health care actually has a massive amount of money, incentives, and policies going towards preventive care -- it's something everyone agrees on. But you're never going to get a focus on preventive care in the way you do on acute care: The politics of health care are about financial and medical peace of mind at the point of absolute need. They're not necessarily rational. If they were, we'd already be running laps and eating 5-11 servings of fruits and veggies, the benefits of which are fully available to us now, and which fully rational, forward-thinking beings would be going to great lengths to take advantage of. Sadly, anyone who's ever been offered decent barbecue knows how rational we are. Damn you, Capps...
