If you can prevent people from getting sick or detect disease early, you can save money for the health care system, right?
Maybe not, says the Congressional Budget Office. So far, in looking at health overhaul bills now moving through Congress, the CBO has failed to attribute any savings to increased efforts to provide preventive efforts like stop-smoking programs.
"It's very Kafka-esque, isn't it?" says Rob Gould, president and CEO of the Partnership for Prevention, an umbrella organization of public health and health industry groups. "We know from our research that some prevention does save money."
Former CBO health analyst Joe Antos, now at the American Enterprise Institute, says preventive services often cost more than they save.
In screening people for cancer, for example, he says, "you screen literally millions of people, sometimes at fairly high cost per screen. You'll pick up some true positives, people who really have the disease. You'll pick up some false positives."
Then all those people have to be followed up by the medical system, which costs even more money. "By the time you're all through — studies have demonstrated this time and time again — screening as a preventive health measure, by and large, doesn't work unless you can narrow it down to roughly the right patient population," he says.
That, however, doesn't make all preventive services cost adders rather than cost cutters. Gould says his group looked at 25 clinical preventive services that were recommended by the U.S. Preventive Services Task Force.
"We found that indeed six of the services did save money and 12 were highly cost-effective," he says.
By cost-effective, he means the intervention cost less than $50,000 per added year of life. By contrast, Gould says, a mechanical device to keep alive a patient with congestive heart failure "is $900,000 for an additional year of life."
While Gould takes issue with the CBO's scoring of the existing House and Senate bills, Ken Thorpe of Emory University takes issue with the bills themselves.
"On the prevention side, at least in the congressional proposals, there is not a coherent, effective prevention strategy really designed to prevent disease in the first place," says Thorpe, who is also executive director of the Partnership to Fight Chronic Disease, another public health umbrella organization.
Thorpe says there are proven ways to use prevention strategies to reduce the incidence of very expensive ailments like obesity, diabetes and high blood pressure. But they need to be more broadly deployed.
Gould, meanwhile, says he worries that even if the bills contained more comprehensive preventive programs, the CBO would still not give them credit for saving money.
Even when the scorekeepers do concede that some prevention and wellness programs do work as intended, he says, "they warn us that living longer would cost the government more money because people would be using additional Social Security and Medicare payments.
"So if the answer to the question is that people would be living longer and healthier lives, then you're asking the wrong question."
The CBO, however, is not charged with deciding whether a bill is good or bad — only how much it costs the federal government. Value judgments are left to members of Congress to make and to the people who vote for them.