What do the campaign platforms of Sens. Hillary Clinton, John McCain, and Barack Obama have in common? Preventive medicine, and the belief that prevention saves money. But does it?

Our "health-care system" is primarily a disease-care system. Last year, $2.1 trillion was spent in this country on medical care, or 16.5 percent of the gross national product. And 95 cents of every medical-care dollar went to treat disease after it had already occurred. At least 75 percent of these costs were spent on treating chronic diseases such as heart disease and diabetes that are preventable or even reversible. A RAND study projected nearly $81 billion in annual national health expenditure savings due to prevention and disease-management programs.

Incentives are often perverse. For example, insurance companies pay more than $30,000 to amputate a diabetic foot even though most amputations are preventable by scrupulous foot care, which is usually not covered by insurance. When I lecture, I often begin by showing a slide of doctors busily mopping up the floor around an overflowing sink, but no one is turning off the faucet. Similarly, Dr. Denis Burkitt (who discovered Burkitt's lymphoma) once said that raising money to pay for ambulances and a hospital at the base of a cliff is not as smart as building a fence at the top to keep cars from falling off.

It's important to treat not only the problem but also its underlying causes. Otherwise, the same problem often recurs (for example, bypass grafts or angioplastied arteries often clog up again), a new set of problems may occur (such as side effects from medications), or there may be painful choices.

Our research at the Preventive Medicine Research Institute (PMRI), as well as the studies of other investigators, have shown that your body often has a remarkable capacity to begin healing itself, and much more quickly than had once been realized, when the underlying causes of illness are addressed. For many people, the choices we make each day in what we eat and in how we live are among the most important underlying causes.
Hillary Clinton's health plan calls for a "focus on prevention: wellness not sickness ... Insurers must cover high priority preventive services that experts agree are proven and effective. This focus on prevention will improve health and lower costs in the long run." John McCain states on his campaign Web site that "We can improve health and spend less, while promoting competition on the cost and quality of care, taking better care of our citizens with chronic illness, and promoting prevention that will keep millions of others from ever developing deadly and debilitating disease." Barack Obama's health plan states, "This nation is facing a true epidemic of chronic disease. An increasing number of Americans are suffering and dying needlessly from diseases such as obesity, diabetes, heart disease, asthma and HIV/AIDS, all of which can be delayed in onset if not prevented entirely." Also, Sen. Ron Wyden has sponsored the Healthy Americans Act, which emphasizes prevention and has bipartisan support.
Given this consensus, many people were surprised by some recent articles questioning the value of prevention. As David Brown wrote earlier this month in The Washington Post, "Studies show it's often cheaper to let people get sick ... Even when prevention greatly reduces future cases of a particular illness, overall cost to the health-care system typically goes up when lots of disease-preventing strategies are put into practice." For example, he questioned the value of taking cholesterol-lowering drugs:

Consider a 50-year-old male smoker whose total cholesterol is in the "high" range (over 240); whose HDL, or desirable cholesterol fraction, is "low" (below 40), and who has untreated moderate hypertension ... If the prevention strategy is taking a statin--a very effective cholesterol-lowering drug--it will cost $160,000 for every year of life saved among men with the above-described risk profile. For women, it will be even pricier: $240,000 for every year of life saved, according to a study published in the Annals of Internal Medicine in 2000.