President-elect Barack Obama's political opponents used to suggest that he's different from the average American. Indeed he is, though in ways that have nothing to do with his unusual name or upbringing. Just look at the man. He's lean. He goes to the gym every morning. When he hits the bottle, it's got water in it. Sure, he has admitted to lighting up the occasional cigarette. But compared with the typical pudgy, sedentary, fast-food-craving American's lifestyle, the president's healthful habits make him anything but average.
As the national conversation about healthcare reform continues, the new president has a chance to do much more than lead by example. Despite the continuing economic uncertainty and a host of competing priorities,
Obama has pledged to keep his campaign promise to bring comprehensive reform to our ailing healthcare system. In contrast to the last big push for reform, during the Clinton administration, this time there has been more agreement among insurers, employers, consumers, and lawmakers on the broad outlines for change. Although many specifics have yet to emerge, all parties agree that any plan must place a strong emphasis on encouraging healthful behaviors and preventing disease.
Reform can't happen soon enough. Americans today are fatter and less active than ever. Two thirds of adults are either overweight or obese, and fewer than a third exercise at least three times a week. Twenty-four million people have diabetes, the vast majority of it related to lifestyle, and an additional 57 million are prediabetic. Despite decades of public anti-tobacco campaigns, 1 in 5 adults smokes. At the same time, nearly 46 million Americans, including 8 million children, lack health insurance.
The news isn't all bad, though. In recent years, we've made inroads against some of the most lethal illnesses: The death rate for heart disease, the No. 1 killer, has declined by 26 percent since 1999. Both the incidence of and death rate for cancer, the second most common killer, are in decline for the first time.
Preventable deaths. But experts worry that progress will be halted or reversed if Americans don't start taking better care of themselves. Take smoking, the leading cause of preventable death. After declining for many years, smoking rates have leveled off and haven't budged for the past five years. Every year, in fact, an estimated 900,000 people die from avoidable causes: because they failed to maintain a healthy weight, eat nutritiously, and exercise, or because they smoked or drank excessively, for example. That's roughly 40 percent of all U.S. deaths.
Our expanding girth is America's most visible health problem. Not only are most adults too heavy, but obesity rates for children have more than doubled in the past 30 years. Excess weight is a significant factor in four of the six leading causes of death: heart disease, cancer, stroke, and diabetes. Obesity has fueled a 45 percent rise in diabetes over the past 20 years; someone born in 2000 has a 1 in 3 chance of developing the disease.
Unhealthful behaviors take a toll not only on individuals' lives but also on our already overburdened healthcare system. The United States spent more than $2 trillion on healthcare in 2006. It accounts for a whopping 16 percent of our gross domestic product, and that's projected to rise to 20 percent by 2017. Much of this healthcare spending can be tied to preventable health problems. For example, obesity-related spending, chiefly to treat high blood pressure and diabetes, accounted for 27 percent of the increase in overall health spending between 1987 and 2001, according to a study by Kenneth Thorpe, a professor of health policy at Emory University. Overall, caring for people with chronic medical conditions, many of them preventable, accounts for about 75 percent of medical spending nationwide.
Given the heavy human and financial cost of chronic disease, heading off a medical condition, or at least its potential complications, seems like a no-brainer. Indeed, politicians frequently extol the money-saving benefits of preventive medicine. In its section on reducing healthcare costs, for example, the Obama-Biden healthcare reform plan says the team will "improve access to prevention and proven disease management programs."
But here's where healthcare reformers run up against an awkward reality: Preventing health problems doesn't necessarily save money. Sure, eating sensibly is free, and so is walking or jogging. But many of the screening tests and other services aimed at early detection of medical conditions cast a large—and therefore expensive—net in order to identify the relatively small number of people who actually have breast cancer, for example, or HIV. The frequency of screening is also a factor; repeated screening may detect more problems earlier, but there's a trade-off in cost.
Researchers put a fair amount of energy into trying to figure out which preventive measures provide the most benefit for the money. One way they evaluate the cost-effectiveness of a particular preventive service is by determining the cost per year of life saved. Breast cancer screening, for example, costs $48,000 per year of life saved, according to estimates from the Partnership for Prevention, a policy and advocacy group. In other words, you have to do $48,000 worth of preventive mammography screening in order to extend one woman's life for one year. Colorectal cancer screening is more cost-efficient; it costs only $12,000 to extend a life for a year.
A few preventive services actually do save money. These include clinicians discussing taking a daily aspirin to prevent heart disease with men over 40 and postmenopausal women; pneumococcal vaccination in adults over 65; and smoking cessation counseling. One of the very best buys is childhood immunization, which prevents children from developing a whole host of diseases for very little cost.
But cost is hardly the only consideration. "The reason to do prevention is to save lives, not to save money," says Ned Calonge, chairperson of the U.S. Preventive Services Task Force. The task force is a congressionally mandated, 16-member panel that reviews the scientific research supporting some 200 preventive services and makes recommendations about which services people should get and when. Members calculate the net benefit of a service—the improvement in morbidity or mortality minus the potential harm—and use that information to determine that cervical cancer screening, for example, should be strongly recommended for women who have been sexually active. Many providers and insurers rely on the task force's recommendations.
If everyone followed the task force's advice, about half of all deaths each year could be prevented, at least temporarily, according to Calonge (no one cheats death forever, of course). But in general, only a fraction of people who should get a particular preventive service do so. Fewer than half of adults age 50 or older have had a colonoscopy or other screening for colorectal cancer, for example, and just over a third of adults in the same age group get an annual flu shot. If 90 percent of people in those two groups got just those two preventive services, 26,000 lives would be saved annually, the Partnership for Prevention estimates.
Experts generally agree that certain screening tests improve the overall health of the population; blood pressure testing is one example. But there's controversy over the value of other tests. Screening can, paradoxically, "make the population less healthy because it leads to so many more diagnoses and to overtreatment," says H. Gilbert Welch, a professor of medicine at Dartmouth Medical School and author of Should I Be Tested for Cancer?: Maybe Not and Here's Why. He cites prostate cancer screening as an example. Since the prostate specific antigen test was introduced in the late 1980s, over a million men have been diagnosed with prostate cancer who otherwise would not have been, Welch says, and up to half suffer serious treatment-related side effects like impotence and incontinence. Prostate cancer deaths have declined since the introduction of the PSA test, but factors other than more aggressive diagnosis—improved treatments, for example—might be responsible for the decline. "We still don't know whether this test helps reduce prostate cancer mortality," Welch says.
An oft-cited reason for people not getting timely screenings and for poor management of chronic conditions is that the healthcare many people receive is fragmented. In recent years, policy experts and clinicians alike have embraced a "medical home" model of primary care that takes a back-to-the-future approach in which patients' primary-care doctors are responsible for managing their healthcare, not just the particular issues that arise in a brief office visit. Medical home practices often employ a team approach to managing care and keep close tabs on their patients with high-tech information technology.
Medical homes also strive to enhance access to care, and patients can often communicate with their doctors by E-mail or make same-day appointments. The American Academy of Family Physicians sponsored 36 medical home practices as part of its TransforMED demonstration project; other professional groups are also experimenting with the model. Geisinger Health System in Pennsylvania reduced hospital admissions by 20 percent and trimmed medical spending by 7 percent by using a medical home model of care, according to a study in the September/October 2008 issue of the journal Health Affairs. But such practices are still rare, and it's too soon to know how they might affect healthcare delivery or costs overall.
At Harbor of Health, a primary-care practice in Memphis that is one of the TransforMED demonstration sites, there are only four chairs in the waiting room. Everybody gets same-day appointments, and patients are whisked into the exam room within five minutes, according to Susan Nelson, one of the physicians there. Even though she spends more time one-on-one with her patients now, they are in and out of the office in just 45 minutes, compared with nearly an hour before. "It's labor-intensive, because you have to be a health coach, and people don't want to exercise or diet," says Nelson.
Homegrown. How we organize our communities and even our own homes may have as great an impact on our health as the way our healthcare system is structured. Communities without sidewalks or bike paths offer little encouragement for people to rely less on their cars. School cafeterias that serve french fries and sugary sodas tempt kids with unhealthful lunch choices.
Rather than leaving it up to individuals to make healthful decisions about diet and exercise, researchers are taking aim at our physical and social environments. "If we can start to shift our systems, it will go a lot farther than trying to reach 300 million people one-on-one," says Christina Economos, an assistant professor at the Friedman School of Nutrition Science and Policy at Tufts University.
Economos led the "Shape Up Somerville" study, a three-year CDC-funded childhood obesity intervention in which researchers worked with the city of Somerville, Mass., to make it easier for children to "eat right, play hard," as the study's slogan puts it. Over the course of two years, school cafeterias—and even local restaurants—changed menus to offer more fruits, grains, and veg-etables. Fatty snacks and sugary drinks were eliminated from lunchrooms. Parents were encouraged to take televisions out of kids' bedrooms. Bike racks were installed at the schools, and trees were planted to create leafy shade over the sidewalks. The changes worked: The city's first through third graders gained a pound less during each of the two years than their peers in two control communities.
But the changes didn't end when the study finished in 2005. Somerville has continued to alter its environment to encourage people to eat smart and play hard, including extending bike paths, creating new parks, and opening farmers' markets.
"This is not about going on a diet," says Somerville Mayor Joseph Curtatone. "This is about social change. We're changing the culture and behavior of people to get them to move in another direction." The reality is, getting Americans to move at all would be a good first step toward health improvement. The nation's new health coach in chief, clearly, has his work cut out for him.