On Prevention, Public Health Policy, and Access

Matthew Yglesias has an excellent post over at his blog.  He notes, in discussing Ezra Klein's post on the trajectory of health care costs:

When it comes to public sector programs, by contrast, there's an argument that if the share of GDP that's going to taxes goes that high, it'll destroy the economy. Incentives, deadweight loss, etc. I don't know that I really think that's the case, but that's the argument you would hear for why runaway Medicare and Medicaid growth is a special kind of horribleness.

Now for my view, there's little evidence that health care spending really helps people, so it really would be a shame -- albeit a survivable one -- for health spending to grow on this trajectory. On top of that, there's good reason to believe that the most effective method of radically restraining health care spending is through full-bore socialized medicine as in the UK's National Health Services. UK health care is slightly worse than what you can get elsewhere, but it's way cheaper and UK health outcomes aren't wildly worse than outcomes anywhere else. Save money by providing universal mediocre health care, à la NHS, leave some of the savings in people's pockets and spend the rest on subsidizing mass transit and bike paths.

As readers are well aware, this is a drum I have been beating for some time here at MH Blog, and one that I will probably continue to sound.  Here are the comments I made (with some links added & slightly edited for clarity) on Yglesias's blog and on Marginal Revoultion, which provides the hat tip:

"For those of you who are interested in the debate over spending on acute care vs. public health and (primary) preventive medicine, see the following posts:

http://www.medhumanities.org/2007/07/on-survivors-co.html

http://www.medhumanities.org/2007/10/on-preventable-.html

http://www.medhumanities.org/2007/10/on-mrsa-prevent.html

http://www.medhumanities.org/2007/06/prevention_rese.html

http://www.medhumanities.org/2007/11/medical-humanit.html

The short of it is that the evidence is indeed overwhelming that acute care does not improve population health very much at all, whereas public health, primary prevention, and social medicine improve it substantially.

The McKeown Thesis by itself illustrates this quite dramatically.  Of course, this also suggests that all of the hand-wringing about slowing the pace of innovation in development of new treatments is just so much fluff, as there is little question that we already have all of the therapies and modalities we need to improve our health outcomes substantially.  This is not to say that innovation is unimportant or undesirable -- though there is solid evidence that technical innovation increases disparities -- but simply to question the reflexive assumption that anything that undermines the pace of that innovation is unacceptable.

What does it say that the vast majority of health policy scholars -- a group in which I count myself -- are expending great amounts of powder and shot debating whether to implement health policies that we have every reason to believe would have little to no effect on actually improving public health?

We would do much better to pay attention to Rudolf Virchow. Though he was the father of pathology, he was anything but a reductionist. He was also the father of social medicine, and he knew that health and illness are primarily caused by social and economic conditions. It is these root factors that are left virtually unaddressed by acute care.   

This is not to suggest that primary care is unimportant.  As I've been careful to note here on MH Blog, none of this means we should not address the moral implications of letting so many go without basic care. But the key here is relative priority, not a false choice between prevention/public health and acute care, but a reordering of our priorities. Think about it: no one is talking about the evidence base for our public health policy; everyone is talking about national health care, so we will likely spend billions of dollars -- in transactional costs involved in switching regimes -- even if we do get national health care, all in the name of a policy that is very unlikely to substantially improve health and reduce suffering."

Thoughts?

Comments

[Patrick S. O'Donnell]

I have nothing profound or interesting to say about the post, agreeing with both its substance and overall tenor. But I do want to mention that I was proud of my fellow citizens who, at the polls on "Super Tuesday," voted down a county-wide ballot measure that would have levied a special property tax increase "to preserve, complete and support Santa Barbara County's Trauma System and Emergency Medical Services Network in order to provide rapid emergency medical care to all people residing in this County."

Now of course many voters have a reflexive reaction against any increase in their property taxes, so I have no idea why people in fact voted against the proposed ballot measure, but suffice to say I was pleased. Why? Well, first of all, I don't recall any debate about this proposal, as it seems to have rather stealthily made its way onto the ballot. My wife, who works at the only hospital in town and is somewhat familiar with the situation at other hospitals in the county, was surprised as well by this proposal, not having heard through the grapevine, as it were, of this urgent need to seek new funds for trauma care. It seems the state law that provides partial funding for "the economic consequences to health care providers and hospitals resulting from the provision of uncompensated emergency medical services" will expire in a year (traditionally, the EMS fund gets its monies from criminal fines and motor vehicle violations), but rather than renew the law, they've authorized counties to collect taxes to make up for the lost revenue. However, the funds from the new measure can be used for other purposes as well, having to do specically with trauma care, and it's not at all clear that these purposes are backed by sufficient evidence of their need. I can certainly think of other reasons for a tax levy that would have a more profound impact on public health in the county, but they lack the glamour and drama of trauma health care.