Health Reform Helps Prevention Flower but Threats Endanger Progress

Larry Cohen	Rob Waters

By Larry Cohen and Rob Waters

Many of us have been working for years to demonstrate the power of prevention to improve people’s health and wellbeing while reducing healthcare costs. For prevention researchers and advocates, passage of the Patient Protection and Affordable Care Act (ACA) was an affirmation of our work and an opportunity to demonstrate the value of prevention.

The Act puts prevention at the center of efforts to reshape the most expensive health system in the world. The words prevent or prevention appear more than 400 times in the bill, and with good reason: Chronic, often preventable conditions such as heart disease, cancer, stroke, diabetes and injuries account for seven of ten deaths among Americans and roughly three-fourths of our $2.7 trillion-a-year healthcare bill. About 40 percent of premature deaths are linked to smoking, poor diet, lack of physical activity and other unhealthy behavior, according to the Institute of Medicine. Preventable injuries are a major contributor to hospital visits, death and costs, with an estimated annual price tag of $406 billion in medical costs and lost productivity.

The Act makes health insurance more widely available, encourages coordination among service providers and payers and incentivizes high-quality—rather than high-quantity—treatment. It also set up grant programs to:

The Act established the Center for Medicare and Medicaid Innovation to foster new ways of embedding prevention and preventive services into the delivery of healthcare in community-center health systems. It created a National Prevention, Health Promotion and Public Health Council headed by the Surgeon General and including a dozen cabinet-level and high-ranking federal officials, along with an advisory group of non-government leaders to advise the Council. These two bodies were charged with devising a comprehensive prevention and health promotion strategy to guide the effort.

It also included this critical element: In the largest commitment ever made by the U.S. government to prevent illness and injury and keep people healthy in the first place, the bill created an ongoing Prevention and Public Health Fund and gave it $15 billion in its first 10 years.

Some of this money went to the Centers for Disease Control and Prevention to help states, cities and tribes develop community-based prevention activities. In 2011, the CDC awarded nearly $300 million in Community Transformation Grants to support local efforts to create safe, walkable streets, promote healthy food environments, support worksite wellness, help children get after-school exercise and reduce exposure to tobacco.

By supporting prevention and health-enhancing community improvements on a broad scale, these investments help shape new values and expectations around the importance of community health and safety. Resulting changes in environment and behavior benefit everyone and reduce the number of people who become injured or develop chronic disease.

Prevention’s cost-saving potential has been demonstrated. In 2008, we at Prevention Institute, with our colleagues at Trust for America’s Health and the Urban Institute, reviewed hundreds of evidence-based studies and identified 84 that measured the ability of interventions to reduce disease by promoting physical activity, good nutrition or smoking cessation. All these interventions were non-medical—meaning they didn’t provide treatment—and all targeted communities, not individuals.

We found that relatively modest investments can result in significant reduction in chronic disease, lowering rates of Type 2 diabetes, heart disease, kidney disease, and other conditions. The economic model we generated found that within two years of initial investment, every dollar would be recouped and an additional $1 would be saved. In the fifth year of investment, our analysis concluded, each dollar invested would lead to a savings of $5.60 in reduced health care costs, not including other benefits such as improved worker productivity and reduced absences from work and school. Scaled to a national level, an investment of $10 per person per year would return $16.5 billion after five years. This analysis was critical in winning the Senate health committee’s strong support for the prevention components of ACA.

Asthma prevention efforts can pay similar dividends. When symptoms flare in people with asthma, they often end up in emergency rooms or hospital beds—expensive, one-off interventions that don’t address the underlying problems and are doomed to be repeated. To change this equation, prevention programs can alter community environments by reducing air pollution and making parks and public spaces smoke-free. They can improve home environments by removing toxic matter—moldy carpets, dust-mite infestations and the like—that trigger symptoms. The CDC’s Preventive Services Task Force found that every dollar invested in home-remediation efforts leads to a cost-savings of $5.30 to $14.

The potential savings from preventing asthma is so dramatic that a firm called Collective Health is now working to attract private investors to finance the first “health impact” bond in the U.S. to pay for home-based interventions in Fresno, California. Private and public insurers would return a portion of the dollars saved to investors. Their efforts may help create an innovative, market-based model to finance prevention efforts.

In 2011, nearly $300 million in Community Transformation Grants (CTG) was awarded by the Centers for Disease Control and Prevention to communities across the country to create safe, walkable streets, promote healthy food environments, support local worksite wellness, help children get after-school exercise and safeguard tobacco-free air.

-In Omaha, Nebraska, 1500 children in 12 after-school programs took part in Movin’ After School, a curriculum designed by University of Nebraska researchers. The programs eliminated sugary beverages, encouraged kids to exercise and received free recreation equipment if they met certain goals. Researchers monitored the programs, identified best practices and are publishing them to guide other efforts. They found that if staff members take a “hands-on” approach, actively encourage children (especially girls) to take part and make use of recreation equipment, kids spend more time being active. Programs using all these strategies achieved the highest participation levels, with about two-thirds of both boys and girls taking part in physical activity.

-In Seattle, 22 corner stores in neighborhoods considered food “deserts” because of their lack of available fresh produce started selling fruits and vegetables, with support from the health department. Another 28 corner stores were coming on line, according to the CDC, making healthier food options available to 650,000 residents.

-Los Angeles set up programs to promote exercise, build community cohesion and cut violence and crime. Parks After Dark offered recreational and social activities to youth and families in neighborhoods with high rates of violence during high-crime summer evenings. The city provided used bicycles to low-income residents, trained them in bike repair and created a social marketing campaign using transit posters and billboards to encourage people to cut down on sugary foods and drinks.

Other programs help urban farms grow fruits and vegetables and farmers’ markets expand, support city planners to set up bicycle lanes and pedestrian paths and bring anti-smoking messages to young people. These programs show how multi-pronged approaches can help people access good food and exercise and have a multiplier effect by spreading beyond the specific sites of interventions to inspire actions in other communities. We saw this with tobacco prevention, where initial efforts in a few communities led to success across the country—even internationally—and a growing consensus that preventive change is doable and makes sense. Such change and consensus starts slowly and its impact grows; we are just beginning to see this kind of impact emerge from the CDC grants.

To have long-term success, such programs need to be maintained and strengthened. The Affordable Care Act’s emphasis on prevention should be just the beginning and serve as a catalyst to a 21st century approach to health. But attacks on the Act—and the Prevention and Public Health Fund in particular—threaten our ability to continue this progress. Some Republicans have called it a “slush fund” and worked to slash its funding level. Early this year, the $15 billion fund was cut by a third to maintain unemployment benefits and avoid cutting pay to doctors in the Medicare program (the so-called “doc fix”). Further attempts to repeal, weaken or raid the fund surely lie ahead.

As researchers and advocates who have worked to build the case for a prevention agenda, we need to celebrate what we have achieved—and recognize the threats that lie ahead. The coming months will be critical for the future of the Prevention and Public Health Fund and we must be prepared to defend it. We must keep making the case for prevention to Congress and to President Obama, as he enters his second term. The next time members of Congress attempt to repeal the Fund or use it as an offset to fix doctor’s fees or fund other programs, we must raise our voices and point out that pitting prevention against healthcare is a false choice. We should encourage our colleagues, especially in the healthcare sector, to join us and say that in order to truly bend the healthcare cost curve, we must keep on investing in prevention.

Larry Cohen, MSW, is the founder and executive director of Prevention Institute. Rob Waters is the institute’s chief communications officer.

The opinions or views expressed in this article are those of the author and do not necessarily reflect the opinions and recommendations of the Society for Prevention Research and its Board of Directors.