Preventative Care?

Does preventative care work? A PLoS study attempted to determine the effects of smoking and obesity on health care expenditures and on life expectancy. The statistical study led to the conclusion that obesity decreased life expectancy, but contrary to popular belief actually increased lifetime health expenditures.

"In this study we have shown that, although obese people induce high medical costs during their lives, their lifetime health-care costs are lower than those of healthy-living people but higher than those of smokers. Obesity increases the risk of diseases such as diabetes and coronary heart disease, thereby increasing health-care utilization but decreasing life expectancy. Successful prevention of obesity, in turn, increases life expectancy. Unfortunately, these life-years gained are not lived in full health and come at a price: people suffer from other diseases, which increases health-care costs. Obesity prevention, just like smoking prevention, will not stem the tide of increasing health-care expenditures. The underlying mechanism is that there is a substitution of inexpensive, lethal diseases toward less lethal, and therefore more costly, diseases [9]. As smoking is in particular related to lethal (and relatively inexpensive) diseases, the ratio of cost savings from a reduced incidence of risk factor–related diseases to the medical costs in life-years gained is more favorable for obesity prevention than for smoking prevention."

Like all statistical studies, the results may be flawed, but this is really besides the point. What if some forms of preventative care actually increase health care consumption? They may be good for public health, but they might be costly. What is the ultimate goal of a public health system. Is it to control costs or to increase public health? It is possible to imagine that these goals can be mutually exclusive in certain instances. How will cost effectiveness be determined? Is cost-effectiveness defined as what is "best" for society or what is "cheapest" for society.

We get into issues of nanny-state activity on the part of government as well. Let's say that prevention of smoking will reduce health care costs. Is it anybody else's business if I smoke (assuming I don't effect their health)? A government run system gives an excuse for further intrusion into the lives of the people in the name of reducing costs. I feel that part of what makes America great is the freedom to make our own choices. Skydiving is unsafe, but we allow it becuase people should have the freedom to choose how to behave. If I am paying for everyone else's health care I want to pay as little as possible. When done through the government, one can imagine restrictions on certain types of behavior in an attempt to reduce people's "burden" on the health care system and on "society." From an individualist's perspective, this is troubling.

Two things are needed:

• Stake in the game: If I am going to participate in unhealthy or possibly expensive activities, I need to anticipate dealing with the consequences of my decision. Assume treating the health problems associated with smoking is expensive, one must be responsible for dealing with these expenses.
• Freedom to choose: What makes life truly fulfilling is the ability to make choices and deal with the consequences of these choices. Restrictions on certain types of behavior in the name of public health or public costs are troubling. Different people have different value systems and make different choices. This is up to them, and I feel that it is somewhat paternalistic for the federal government to disallow certain behaviors. We must resist the urge to try to minimize people's burden on the system. I expect we'd be unhappy with the results.

I am open to preventative medicine, especially if it is cost effective and would help public health. But I wonder, if it really is cost-effective why is it not being done today? Is it because people do not have enough skin in the game or is the profit-motive for insurance companies broken?