Improving Public Health Through Prevention

By Neal Halfon, The American Prospect. Posted June 5, 2008.

The case for universal health-insurance coverage is becoming universally acknowledged. To make a real difference in health outcomes, cost, and system performance, we need to cover the whole person, with a full continuum of appropriate care, and ensure continuity over a person's entire life. Anything less will perpetuate inefficiencies and poorly coordinated coverage, which engender fragmented and poor-quality care. But universal coverage alone is not sufficient to reduce the remarkable 35-year difference in life expectancy across different classes of Americans. Universal coverage alone is also not likely to greatly improve the United States' ranking of 46th in life expectancy and 42nd in infant mortality among 192 nations. A high-performing national health-care system must also focus on the prevention of disease and promotion of optimal health for all its citizens.

Effective prevention strategies are not just about routine screening tests provided by doctors in offices or clinics. They are also about methodically addressing the factors that determine health and disease. The inconvenient truth is that many important health determinants -- including numerous risky behaviors and social environments that systematically expose people to toxic stress -- promote undesirable food choices, limit opportunities to exercise, and usually fail to respond to even the best prevention efforts dispensed by our personal physicians.

Over the past few decades, in particular since our last attempt at national health reform in the early 1990s, important new research has transformed our understanding of what determines health. We know much more about how particular diseases, such as heart disease, evolve over decades and how environmental influences align to channel long-term health outcomes. The policies developed to reform the health-care system, and the ways in which we judge the system's performance over the coming years, should incorporate these paradigmatic shifts in our knowledge about what triggers disease and determines health. Our policies need to encourage innovation in the organization, financing, and delivery of health services that exploit this new knowledge to catalyze genuine improvements in the nation's health.

What our country really needs is "Universal Coverage PLUS" -- universal coverage that can also address the social, behavioral, and environmental determinants of health. We need to bring prevention and health promotion from the fringe to the core of the health system. Such an approach would re-engineer the health system to promote the health of individuals over the long periods during which health problems develop. To this end, our specialty-dominated health-care system should be turned on its head, so that a new and more robust form of primary health care can emerge. Moreover, health-care funding needs to expand beyond paying for individual care. We will get much more bang for our health-care buck by making strategic investments that promote the health of specific populations and communities. A sensible place to inaugurate this Universal Care-PLUS approach is with kids. With universal coverage for all Americans as the foundation, additional systemic reforms that transform the way in which we prevent disease and promote optimal health among children and adolescents will be an important down payment on future health returns and serve as an important national pilot for an innovative and necessary new health system that has prevention and health promotion built into the DNA of its basic operating logic.

The Promise and Limitations of Universal Coverage

The central goal of health-care reform efforts for most of the last century has been universal coverage. If enacted, universal coverage could eventually improve health and decrease health-care cost by bringing everyone into the same system, encouraging ties to a medical home, reducing the use of inappropriate and costly emergency room visits, mitigating the inefficiencies of interrupted care caused by coverage problems, and providing effective preventive interventions like regular mammograms, PAP smears, and other cancer screenings. The international experience shows that universal coverage can ensure access to acute medical care when individuals become ill, chronic disease management for the growing number of people with disabling chronic health conditions, and many preventive services that can avert or postpone the onset of disease.

These same cross-national comparisons, however, strongly suggest that universal coverage alone is not sufficient to achieve our national health and health-care goals. Even countries that have had universal coverage in place for several decades still have significant health disparities associated with the socioeconomic, behavioral, and environmental determinants of health. The now-famous Whitehall studies of British civil servants, for example, revealed how relative social status has continued to play a major role in the prevalence and impact of a range of chronic diseases from cancer to heart disease, even though the entire British population is fully insured. Civil servants that were higher up the pecking order, had more control over their lives, were more able to use what the system had to offer, and were more sophisticated in optimizing their health.

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Neal Halfon, M.D., MPH, is professor of pediatrics, health services, and public policy and directs the UCLA Center for Healthier Children, Families and Communities. Halfon also directs the Blue Sky Health Initiative, whose core team contributed to this article.

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