The Politics of Prevention

Really? McCain's plan specifically calls for more of those programs.
COHEN: They're probably the most complicated of all the programs I've looked at. If they work and people live longer, you prevent illness in the near term, but you extend life in the distant decades when people are older and their care is costly. So it depends on how you do your accounting.

NEUMANN: It's also easy to say "more people should eat well and exercise and not smoke," but will people adhere to that advice? If they don't, we're not going to get a big return on our investment in health-education programs.

Is there a general rule about what kind of preventive care government should pay for?
NEUMANN: It's usually more efficient to target high-risk populations.

COHEN: You also want to know how many people you have to screen or treat to prevent one case of disease and how much each screening costs. Checking my blood pressure is pretty inexpensive. Doing an MRI is going to be much more costly, perhaps by orders of magnitude. And it's good to look at the nature of the disease that's being prevented. Let's say hypothetically I have a medication that prevents Alzheimer's. That could cut way down on the years people spend in a disabled state, and those years eat up a lot of money. On the other hand, if I have a medication that prevents something that kills rapidly with little disability, it may save lives but it won't necessarily save money.

Prevention also isn't very precise. Once a person is sick, we know he needs help—
NEUMANN: Whereas it's not always clear who's going to be a train wreck in the future. When you intervene early you pick up train wrecks, but also people who were slightly at risk or weren't at risk at all. Also, part of what advanced medicine helps us do is detect small risks, and we're going to pay for that. As we gain more ability to detect small risks and intervene when we find them, costs will go up.

Are you saying it's sometimes cheaper to treat a sick person than it is to keep him healthy?
NEUMANN: Some advanced treatments are more efficient. But I think we have to be careful with "cheaper." The cheapest thing might be do nothing and let the person die. The goal is not to save money—it's to improve health and get the best value from our spending.

COHEN: If we claim we want to do prevention because we don't want people to have a particular disease, that's fine. But if we claim we're doing it because it saves money, that's not always being honest.

Obama's plan says we need to study which health-care strategies work best. In light of that and also your work, what do you make of his plan? And McCain's?
COHEN: If a politician is going to go through these measures carefully and find the ones that do in fact deliver, that would be great. But it's something to ask them both about at the debates. "You claim this will save money. How?" I'm sure they'll have an answer. At least I hope so.

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