Health care reform debates will continue to swirl around cost. The most vocal participants across the political spectrum rail about the chunk of our GDP dominated by health care, the bills that bankrupt families, and the lack of affordable coverage options. Whether they believe in private or public-sector solutions, they all recognize that changes must be made. But such debates rarely include discussions about the demand-side, namely the role of preventable chronic diseases as both adriver and amplifier of costs. If fewer people develop these conditions, demand will go down. Public healthneeds to be making this point loudly. Every time there is a politically divisive argument over single-payer vs. private insurance, or market self-correction vs. regulation, public health advocates need to be there saying “there is a better way to make this system manageable.”
While economists will tell us that it is difficult to predict exactly what effect demand reduction would have on our incomprehensible health care “marketplaces,” economic theory indicates that this would reduce costs. What’s more evident is that demand reduction would be immediately beneficial for public and private payers. Most importantly, preventing chronic disease will dramatically reduce the economic burden for consumers themselves, freeing up their resources for other life essentials. The prevention argument is simple to make: “let’s focus on not needing so much health care in the first place.” It is an obvious point that appeals directly to core American values of thrift and common sense. So why isn’t it a part of the debate?
Pundits don’t talk about demand because the experts they listen to also don’t talk about it. A February 2018 report from the Network for Regional Healthcare Improvement (NRHI) comparing cost drivers across five states is a great example. Entitled Healthcare Affordability: Untangling Cost Drivers, the authors do not even mention chronic diseases as a cost driver. The report is entirely focused on factors they see as within the health care system, despite the absurdity of considering anything external to an industry that dominates nearly 20% of our economy. The closest they come to mentioning demand is discussing disparities in use patterns, for which there is not yet a clear explanation:
“Outpatient resource use in Colorado was 25 percent above the benchmark, the highest percentage above the average in any category in any participating state. Coloradans also had the highest utilization of prescriptions, at 23 percent above the benchmark.”
It might be important to find which structural inefficiency is causing this disparity, but the burden of preventable disease that is likely behind most of this pattern is undeniably the more critical factor. The authors seem to be ignoring this. Also, what guarantee do we have that the cost reductions resulting from increasing efficiency in health care delivery will be passed on to consumers or even payers?
Pundits aren’t the only people paying attention to such reports. Policymakers rely on them when planning reform efforts. An alliance of seven governors, including Colorado’s, just released their new plan called the Blueprint for Improving Our Nation’s Health System Performance. Most solutions they propose are also limited to similar within system factors found in reports like NRHI’s that realign incentives and increase efficiency. The plan contains only the vaguest nod to the demand-side, suggesting that reforms should “encourage responsible choices by empowering consumers with useful information and incenting healthy lifestyles.” This statement at least hints at more demand-side considerations, but it certainly does not reflect current thinking in primary prevention. It echoes sentiment from public health 1.0, which prioritized individual behavior change over addressing systemic factors.
As a hopeful if not substantive gesture, both approaches do claim to be considering many factors at once. The NRHI references the “health care cost balloon” metaphor, which describes how squeezing one side just moves air to another. As one of its core beliefs, the Blueprint states that “the best strategies to improve our health care system address multiple objectives simultaneously.” This indicates that both pundits and politicians perhaps are open to a more systems-thinking approach that at the very least doesn’t ignore the obvious.
How do we meaningfully enter the conversation? To start, we can openly criticize reports like NRHI’s. Public health can directly answer their myopic conclusions with op-eds and articles in academic journals. Public health can also join politically charged debates in the mainstream press on health care reform. Our message is simpler and saner, and for most people it will be a breath of fresh air. Concurrently, public health can continue to demonstrate its value at the local level by involving more community members in its programs and planning, so they can recognize and celebrate its successes. If they are involved in community health prevention efforts, then such efforts will no longer be invisible to them.