Recently, Sen. Tom Harkin was asked to lead a working group given the task of crafting the prevention and public-health components of President-elect Obama's health-care-reform bill. As chairman of the subcommittee on appropriations and health, he's in a position to have a pivotal role in tackling the immense challenges the nation faces in this area. He spoke with NEWSWEEK's Dean Ornish about his vision for health-care reform. Excerpts:
Dean Ornish: Why you are so passionate about preventive health care?
Tom Harkin: I want to lay down a marker right here at the outset of America's great debate about national health-care reform: if we pass a bill that greatly extends health-insurance coverage but does nothing to create a dramatically stronger prevention and public-health infrastructure and agenda, then we will have failed. I have long believed that prevention and wellness are the keys to solving our health-care crisis. We must recreate America as a "wellness society" focused on fitness, good nutrition and disease prevention—ultimately, keeping people out of the hospital in the first place. You paved the way for a lot of people, and this is something I have been laboring on for a long time.
We don't have a health-care system in America; we have a "sick care" system. The problem is that this current system is all about patching things up after the fact. We spend untold hundreds of billions [of dollars] on pills, surgery, hospitalization and disability. But we spend peanuts—about 3 percent of our health-care dollars—for prevention.
When President-elect Obama recently introduced former senator Tom Daschle as the new secretary of health and human services, he said, "Now, some may ask how at this moment of economic challenge, we can afford to invest in reforming our health-care system. But I ask a different question. I ask, 'How can we afford not to?'"
Every year, we keep putting more money into high-tech, very expensive remedial things. And yet, we know there are better, safer, more cost-effective ways of dealing with many of our chronic illnesses.
Heart disease is a good example. More than $30 billion were spent last year on angioplasties, yet randomized trials clearly show that they don't prolong life or even prevent heart attacks for most people. In contrast, studies show that most heart disease is completely preventable today, simply by changing lifestyle. My colleagues and I have shown that heart disease is usually reversible by changing lifestyle. So, why has it been so hard to reform health care?
It's been so hard because the deck is stacked, socially and economically, against the kind of preventive measures that are cost-effective and that evidence has shown work. From the earliest time, our kids are led into eating unhealthy foods.
I'm encouraged that some of the large companies, like PepsiCo, are finding that it's good business to make healthier foods, which makes it sustainable. What can we do to encourage kids to eat more healthfully?
We can start at the earliest times in a child's life, like the Women, Infants and Children's Program, to make sure that mothers get healthier foods. This next year coming up is the reauthorization of the Child Nutrition Act, and that's under my jurisdiction. Making sure that kids in the Head Start Programs get early education and information about what is healthy and what is good and have healthy snacks for them, too. In 2002, I took a few million dollars and I started a free fresh fruit and vegetable snack program in schools. My theory was this: if kids could get a fresh piece of fruit or vegetable for free, they would eat it. And if they would eat it, they wouldn't get the "growlies" and wouldn't be rushing to vending machines or eating cookies. People always say, "Well, we will put a couple of apples or oranges in the vending machines," but kids aren't going to buy that with their money. But if you give it to them free, they will eat it.
Kids get these little packages [in the program]—apples, oranges, broccoli and baby carrots are already sliced for them. In the current farm bill, I fought very hard and I got $1 billion for this program. Within five years, we'll be able to get close to 90 percent of all the elementary-school disadvantaged kids a high level of free and reduced-priced lunches. These kids are now eating fresh fruits and vegetables.
People get their taste preferences when they're young, so if we can get kids enjoying healthful foods like that when they're young, they're much more likely to do so when they're older.
Absolutely. A lot of these kids getting these fresh fruits and vegetables at schools are going home and asking their parents to get them. I was at a fourth-grade class, mostly poor kids, and they were having fresh oranges, and there were kids who had never had a fresh orange in their life.
As you know, many of the subsidies in the farm bill are perverse, making it significantly cheaper to eat fat, salt and sugar than fresh oranges.
Well, we're changing that. For the first time ever, I got fruits and vegetables included in the farm bill. We spend a staggering $2 trillion annually on health care, more than any other nation in the world, yet the World Health Organization ranks U.S. health care only 37th among nations. Thirty-seventh! We are 20th out of 21 industrialized nations in the quality of health care for children. When I look at these statistics, it seems as though we have lost our capacity to be shocked or outraged. Just how much evidence do we need that America's approach to health care—or should I say sick care?—is not working?
The only state that mandates physical education in schools is Illinois. That's another approach that red states and blue states can get behind: getting exercise back in our schools. As you know, exercise and better nutrition improve academic performance as well.
Exactly. I'm looking at tying reimbursements for school meals to schools that have a physical exercise program, and/or giving bonuses to schools that have an exercise program.
The Robert Wood Johnson Foundation [a philanthropic organization dedicated exclusively to health and health care] has shown that when you change public infrastructure, it really does change behavior.
I put an amendment in the last highway bill that said that any state or local government that gets federal money for highways, bridges or streets would have to incorporate in their planning bike paths and walking paths. It lost, but part of my wellness initiative is to use the finance committee to put out tax incentives to workplaces that offer comprehensive wellness programs. Allocate more Medicare dollars for early diagnosis and prevention with no copays—if you have a colonoscopy, there shouldn't be a copay; there shouldn't be a deductible. We waste so much money in Medicare. For example, Medicare will not pay for any kind of diet or nutrition counseling if you are pre-diabetic.
But they'll pay to amputate your foot …
… After you get diabetes. It's just nuts. So these are the things we've got to change. A robust emphasis on wellness is about saving lives, saving trips to the hospital and saving money, and it's the only way we are going to get a grip on skyrocketing health-care costs. To date, prevention and public health have been the missing pieces in the national conversation about health-care reform. It's time to make them the centerpiece of that conversation. Not an asterisk. Not a footnote. But the centerpiece of health-care reform.