Prevention Matters

The Robert Wood Johnson's Commission to Build a Healthier America was launched in February 2008 to find out why Americans aren’t as healthy as they could be and to suggest ways outside the health care system to improve health for everyone.

The commission is wrapping up its duties and closing its doors after two years in which it has issued two major, held regional field hearings, national events and more than 50 meetings with public and private sector leaders.

"This Commission was not the first time this country has addressed health disparities or the social determinants of health – but it’s the first time in a long time that we have been able to look at these issues squarely in the face and have hope," says RWJF President/CEO Risa Lavizza-Mourey.

"The Commission crystallized for all of us that health is more than health care. Health is where and how we live, learn, work and play," she says. "So, reaching beyond traditional health care communities is essential if we are going to make any headway in improving the health of all Americans."

Lavizza-Mourey further discusses the closing of the commission and the importance of its work in a recent podcast.

The following is a guest post from Partnership for Prevention President Robert J. Gould, PhD, and Executive Vice President Corinne G. Husten, MD, MPH., that appeared on the blog for the Robert Wood Johnson Foundation's Commission to Build a Healthier America.

When the answer is that living longer is a problem, you know you’re asking the wrong question.

The Congressional Budget Office recently issued a memo identifying areas where Congress could save money in a health reform bill. When it came to disease prevention and health promotion, the logic in its response was troubling.Promoting healthier lifestyles may help reduce the prevalence of costly chronic diseases, the CBO said, but the "overall budgetary effect also depends on the cost to the government... by people who live longer." It said such people could cost the government more in terms of health care costs and Social Security payments generated during their additional years of life.

Too often, the notion of investing more in prevention is being summarily dismissed on the grounds that prevention “doesn’t save money.” Such assertions have been repeated of late by articles in CQ (here for subscribers) and The Wall Street Journal. Those critics are asking the wrong question, and the answer to that question turns logic on its head. The proper question should be: what gives us the most bang for the buck?

Here are the facts: some preventive measures save money, while some don’t. Some medical treatments cost more than others. In each case, some are more effective than others in terms of improving health. But those facts should not result in a blanket dismissal of prevention. Even when preventive measures cost money, they offer tremendous benefits at a relatively low cost.

Partnership for Prevention conducted an extensive review of clinical preventive measures – those that can be performed in a doctor’s office. We found five measures that, if used more broadly, could altogether save an additional 100,000 lives a year. Three of those measures – daily aspirin use, tobacco cessation counseling, and colorectal screening – actually save money as well as lives. The other two – flu immunizations for older adults and breast cancer screening – save lives and are still more cost-effective than most medical treatments. Even so, all of those preventive measures remain under-utilized, due partly to lack of public awareness and partly to deductibles, co-pays and lack of coverage that can discourage clinicians from recommending those services and discourage patients from having them performed.

In a separate study, we reviewed the 25 preventive services recommended by the US Preventive Services Task Force. It found that six of them actually saved money, while 12 were highly cost-effective in that they cost less than $50,000 for each year of life saved. That compares with an LVAD device that helps keep alive heart failure patients who can’t get a transplant – which costs $900,000 per each year of life saved.

As for helping people live longer, prevention pleads guilty as charged. But should we really put proponents of prevention in the Orwellian position of apologizing for helping people live longer, healthier lives? Expensive medical treatments for people who are already sick also help people live longer. But isn’t that the whole purpose of our health care system?

Our current system doesn’t provide value, as evidenced by our low ranking in health status among industrialized countries. But prevention can help change that, because prevention provides great value. The investment to cover and pay for preventive services produces tremendous returns, and providing and increasing utilization of these services will create a much more efficient health care system.

Meanwhile, private-sector companies are reporting phenomenal results from implementing science-based wellness and prevention programs in the workplace. Safeway CEO Stephen Burd said in a recent Wall Street Journal op-ed that the wellness program his company started in 2005 has kept its health care expenses flat while those expenses increased by 38 percent nationally. Dow Chemical Company says that its wellness program saved the company more than 9,000 employee absentee days last year alone and had a return on investment that was equal to seven cents a share of company stock. Pitney Bowes estimates that its health promotion initiatives have saved the company $40 million over nine years.

Perhaps that’s why a recent survey of Americans by the Trust for America’s Health and the Robert Wood Johnson Foundation showed that 77 percent of Americans believe prevention will save money. Even more importantly, it showed that 72 percent of Americans favor increased investment in prevention, even if it didn’t save money.

It’s critical that we conduct widespread cost-effectiveness research to find out what delivers the most health at the least cost are critical. Prevention measures should be a part of that research, so that we can find the way in which our health care system can make the most effective and the most efficient use of both prevention and treatment services. In the meantime, we hope Congress will increase the nation’s investment in high-value preventive services that help people live longer, healthier lives.

Is prevention a “panacea for cost savings?” No, but that’s not the question. The real question is: is prevention a proven, cost-effective way to improve our health and our health system. The answer to that question is “yes.”

For the first time in our nation’s history, today’s generation of children may well live sicker, shorter lives than their parents. To improve America’s health, we need to understand why, across social boundaries and in every community, so many Americans are getting sick in the first place.

To answer that question, the Robert Wood Johnson Foundation Commission to Build a Healthier America spent the last year and a half investigating the powerful influence that factors beyond health care – where we live, learn, work and play – have on our health. As staff director, I had the privilege of joining the diverse group of commissioners in talking with experts, leaders and citizens across the country as the commission developed its recommendations.

We have good news: From business to government and at all levels of society, leaders and citizens are collaborating to remove obstacles that prevent people from making healthy choices. Where communities have mobilized to improve their health, we found grocery stores well-stocked with nutritious food, streets that were safe to walk, housing that was maintained, workplaces that promoted wellness, and a commitment among schools, child-care centers and parents to give all children in the community a chance to grow up healthy.

The commission released its recommendations in April to highlight these local successes. But the commission did not stop at identifying programs and policies and learning why they work. As Partnership for Prevention understands well, great ideas will go nowhere without equal efforts to educate decision-makers and engage stakeholders towards action. To that end, the commission is actively facilitating collaboration across communities, businesses, unions, philanthropies, and local, state and federal governments to help bring the recommendations to life.

Specifically, the commission recommends:

• Making education and high-quality child care a national priority


• Banning junk food in schools. Federal funds should be used exclusively for healthful meals


• Getting kids moving. All schools (K-12) should include at least 30 minutes every day for children to be physically active


• Eliminating so-called food deserts. Create public-private partnerships to open grocery stores in communities without access to healthful foods


• Creating incentives for healthy, safe development by assigning a health impact rating to housing and infrastructure projects


• Providing employees opportunities to make healthy choices in the workplace


• Protecting us all from tobacco smoke. Eliminating smoking remains one of the most important contributors to longer, healthier lives

You can read all the recommendations and learn more about model programs at commissiononhealth.org.

Building a healthier America is feasible in years, not decades, if we collaborate and act on what is making a difference. I encourage you to read the commission’s recommendations and to do your part to make America’s health a place of progress once again.


Dr. David R. Williams is a Professor of Public Health at the Harvard School of Public Health and the Staff Director for the Robert Wood Johnson Foundation Commission to Build a Healthier America.

Anyone familiar with Partnership for Prevention’s work and activities knows that “real health reform starts with prevention.” Implicit within this assertion is the conviction that the issue is health reform, not just health care reform. Partnership has always promoted this idea-it is the central premise of our Principles for Prevention-Centered Health Reform and all of our health reform recommendations.

Robert Wood Johnson Foundation’s Commission to Build a Healthier America further developed this theme with the release April 2 of its 10 recommendations for improving the nation’s health. By concentrating on evidence-based interventions and programs that are outside the health care system, the Commission emphasizes the need to have a broader view of health to generate a healthier nation.

Three aspects of the recommendations are particularly worth noting:

• The Commission addresses the main causes of poor health. Half of the recommendations deal directly with the three primary actual causes of death in the United States-smoking, poor diet, and physical inactivity;
• The Commission focuses on working as “upstream” as possible in the age continuum. Determinants of health and health behavior habits start early in life, therefore any policy or program implementation must begin with our children; and
• The Commission recognizes the role that non-health factors play in the health of the country. Policies related to transportation, housing, infrastructure, agriculture, and the environment all have a “health impact,” and developing healthy communities requires measuring that impact.

Finally, these recommendations are consistent with Partnership’s emphasis on the significance that community prevention plays in health reform, and we look forward to collaborating with the Commission and other partners to advance interventions that will have a greater impact on health than increased access to medical care, improved health insurance coverage, less medical errors, or health IT. As we say in our principles, “The nation will get a much greater return on investment by focusing on health improvements in communities, schools, and worksites rather than focusing solely on what occurs in traditional healthcare settings, such as doctors’ offices and hospitals.”

Read more on Partnership’s health reform efforts at www.prevent.org/healthreform. The Commission to Build a Healthier America’s recommendations can be found on its website at http://www.commissiononhealth.org/.

- Jason Spangler, MD, MPH