Solving the Health Crisis: Timing and Responsiblity

There are two separate, though related, issues of timing when it comes to solving, or at least ameliorating the health crisis affecting the world. First is the basic question of when in the development of disease and injury should we focus our efforts. The US, and to a great extent, the world’s “health system” is chiefly focused on reactive health care, on diagnosing and treating states of “unhealth” after these arise. But most experts agree that the best solution, in at least most cases, is to proactively intervene before unhealthy occurs, to reduce the incidence and prevalence of unhealthy in the first place, wherever it can be accomplished cost-effectively. [R. Pear “New Health Initiatives Put Spotlight on Prevention” New York Times Apr 4m 2010 (www.nytimes.com)]

It is not that this is a new idea. Public health experts have long argued for “moving upstream” vs. spending virtually all efforts on rescuing those already afflicted. But the “system” is almost wholly devoted to rescuing, and a huge portion of the economy is dependent on revenue generated thereby. While the pharmaceutical industry has embraced prevention to some degree, what will happen to all those hospitals and physicians if we won a “war” on sickness?

Moreover, prevention is by no means the most cost-effective option in all cases, nor even in most cases, at least so argue many health gurus. And even if prevention is the best option, there remains the question of who should pay for it? Everyone seems convinced that one essential is that consumers should take greater responsibility for managing their own health. But this is a silly philosophical argument unless we figure out how to achieve such a “consummation devoutly to be wished”.

Except for the sick care industry dependent on the failure of preventive efforts, virtually every employer, insurer, government, and consumer would be better off if there were less sickness around. But employers, at least, are striving mightily to shift the costs of health insurance to government, taxpayers, and employees where possible. Insurers have only lately begun to invest in prevention, since they do not have the responsibility for paying the costs of individuals’ sickness long enough, in most cases, to make investments that don’t pay off for years.

Government seems to be persuaded that prevention, from primary to secondary to tertiary, doesn’t pay off well enough – and it is often as short-term focused as are insurers. Employers have learned that healthier employees are more productive and deliver greater economic value to their employers thereby, so most are investing separately in prevention via wellness and health promotion, even while reducing their investments in sickness care insurance.

The second timing issue relates to when in the lifetimes of people, is the best time to invest in prevention. On the one hand, the federal government seems to believe that waiting until people are eligible for Medicare is too late, while covering prevention for Medicaid mothers and children makes sense. Increasingly, it is being recognized that “prevention” is best adopted early in the life of individuals, whereas epidemics of obesity, diabetes, heart disease, and other expensive chronic conditions are initiated early. [L. Carroll “Mid-Life Health Ills Take Root in Tots” MSNBC.com Apr 5, 2010]

If babyhood and young childhood represent the most cost-effective opportunities for prevention, at least for instilling healthy diet and exercise habits, who will take responsibility for that? Parents are increasingly absorbed in generating enough income to survive and live the life they wish, while relying on day care and schools to “develop” their children properly. Schools are hardly able to meet their traditional educational roles, much less add on responsibility for producing healthy children.

While insurers share an interest in promoting healthier populations early on, the only time it makes sense for them to invest in prevention of unhealthy in children is when such children are listed as dependent “members” of the health plan for which the insurers are responsible. If the payoff from prevention among children is many years, often decades off, what economic sense does it make for insurers, or employers for that matter, to invest now?

It can be and has been argued forcefully that consumers ought to be the ones responsible for investing at least time and effort in the health of their children and themselves. But how can all or most of us be persuaded, encouraged, motivated, empowered, and reminded to do so at the most appropriate time and place, while using the most cost-effective methods? If it “takes a village” to raise a child, it certainly takes a large part of a country and its economy to achieve real health in its population.

Already, there seems to be great willingness to shift responsibility for preventing mistakes in sickness care to patients and families, to shift as much responsibility for the care of elderly to family members. Shifting more of the burden to consumers for prevention and health promotion will always seem attractive to institutions that would have to bear the responsibility otherwise. But can it be done?

We should be able to agree that the timing of care should be shifted to before rather than after people are sick, wherever cost-effectiveness is greater with earlier interventions. We should also be able to agree that timing interventions as early in the life of individuals should be practiced wherever the most cost-effective results come from such interventions. But until we focus on devising and implementing ways to enlist the most cost-effective coalitions of who’s responsible, we will be simply arguing, rather than acting.