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How to make U.S. health care more efficient

Dr. Jody HeymannDr. Jody Heymann is dean of the UCLA Fielding School of Public Health, an elected member of the Institute of Medicine, and distinguished professor of epidemiology, medicine and public policy at UCLA. Douglas Barthold is an economics doctoral candidate in economics, and a doctoral fellow at McGill University's Institute for Health and Social Policy. This op-ed originally appeared Dec. 16 on CNN.



Worried about what your new mandated health insurance will cost next year? We should all be worried, but it has little to do with the Affordable Care Act. Over the past two decades, the United States has run near the top of the pack in a competition no country wants to win – spending the most while getting the least.


The American Journal of Public Health published the results of our study examining health systems of 27 high income countries over 17 years, and their efficiency at turning dollars into extended lives. The United States was near the bottom, ranking 22nd. Every hundred additional dollars spent in the United States was associated with a gain of less than half a month of life. In Germany, more than four months of increased life expectancy were associated with every additional hundred dollars spent.


Not everyone does equally poorly in the United States. Our new study has the U.S. ranking 18th when it comes to the efficiency of investments in reducing men’s deaths. Worse yet, when it comes to reducing women’s deaths, the U.S. ranks 25th.


This is not an abstraction. In previous research, Ellen Nolte and Martin McKee found that in a mere five years, between the late 1990s and early 2000s, the U.S. dropped four positions in global death prevention rankings. How much does it matter? If preventable deaths in the U. S. looked like the average across France, Japan, and Australia, more than 100,000 fewer people under 75 would die each year.


How did we end up with one of the advanced economies’ most inefficient healthcare systems? How do we manage to have so many preventable deaths?


The short answer is that we are willing to spend almost anything as a country once you are dying – not to make you more comfortable or to ensure you have more meaningful time with your family, but rather in an effort to keep you alive a few extra days at a time when the dollars yield little advantage.


The problem is that, as a nation, we have not been willing to spend anything on preventing people from getting sick. And what really contributes to whether you’re likely to die prematurely is whether you get sick in the first place.


The U.S. spends $2.65 trillion per year on health care. The Affordable Care Act had earmarked less than 1/10th of 1 percent of this for prevention. The only thing both parties seemed to agree on was to eliminate that small amount of prevention dollars. The Republicans labeled it a slush fund, and the Obama administration, in the absence of other dollars for implementing the ACA, was all too ready to raid it. So the actual dollars spent on prevention in the ACA last year were less than half of the miniscule amount first allocated.


In fact, helping people get sick is institutionally embedded in some of the actions of Congress. Because a presidential primary is in Iowa, subsidies have been provided to the production of corn, also sometimes used to produce high fructose corn syrup, which has been linked by studies to obesity.* The Congressional Budget Office typically assesses a cost to prevention programs in any new bill, but usually does not allow the bill to count the savings that occur — they are considered too far out into the future. As a result, prevention is often left out by legislative staff, to improve the CBO score.


Yet there’s a great deal we know about what works. If in the workplace and at school you take a 10-minute recess every day to exercise, your body mass index will go down, as will your risk of diabetes and heart disease. It’s free. There’s no company or stakeholder that will make money off of it. But you’ll be healthier, there’ll be fewer premature deaths in the U.S., and our healthcare will cost less.


When healthy food and fitness options are available in our schools, the epidemic of childhood obesity and early onset diabetes can be reversed. In its absence, we will continue to see the tripling of diabetes costs we saw in a generation. Policies that kept smoking out of schools, workplaces, and public places saw a dramatic decline in smoking rates in the U.S., and in illness and deaths associated with smoking. When we set our mind to it as a nation, we know how to make prevention work.


So yes, we need a health insurance system that covers all Americans. And we should all worry whether it is affordable. But the only way to make it affordable, and to improve the health of Americans, is if we start to seriously invest in preventing people from getting sick in the first place.