Senate Democrats

Health Care Reform: The Need for Prevention and Wellness Efforts

A renewed focus on prevention and wellness policies is necessary to transform our current “sick care” system into a true health care system.  Of the more than $2 trillion the United States spends on health care each year, only four cents out of every dollar is invested in prevention and public health, despite studies showing that disease prevention can effectively reduce health care spending.[1][2][3]  This limited investment results in low utilization of prevention services, with studies finding that American adults receive just half of all recommended clinical preventive services.[4]

Without a focus on prevention and wellness policies, Americans needlessly suffer and die from uncontrolled chronic conditions, which are exacerbated by our nation’s obesity epidemic.  Additional efforts are also needed to encourage Americans who smoke cigarettes to quit, and to ensure those who don’t smoke never start.  With just a small investment in prevention and wellness, we can make it easier for Americans to make healthier choices, avoid chronic disease, and live long, healthy, and productive lives. 

Chronic Disease

More than half of all Americans live with one or more chronic conditions, and chronic diseases are responsible for seven out of ten deaths in the United States.[5][6]  Specifically, five chronic diseases – heart disease, cancer, stroke, chronic obstructive pulmonary disease, and diabetes – are responsible for more than two-thirds of all deaths in the United States.[7]  The cost of caring for individuals with chronic diseases accounts for approximately 75 percent of the more than $2 trillion Americans spend on health care each year.[8]  Reducing the incidence of chronic disease is a key to reducing the overall cost of health care.

Heart Disease.  Heart disease is the leading cause of death in the United States, accounting for approximately 35 percent of all deaths each year, and resulting in direct and indirect costs of $475.3 billion in 2008.[9]  Approximately 80 million Americans are living with heart disease.[10]

Cancer.  Estimates indicate that more than 560,000 thousand Americans will die of cancer in 2009, making cancer the second leading cause of death.[11]  In 2008, the National Institutes of Health estimated total cancer costs to the nation of $228.1 billion.  Approximately 11 million Americans are living with or have a history of cancer.

Stroke.  Strokes account for approximately one of every 17 deaths in the United States, and are the third leading cause of death.  Direct and indirect costs due to stroke are estimated to be $68.9 billion in 2009.[12]

Chronic Obstructive Pulmonary Disease.  Chronic obstructive pulmonary disease (COPD), which, according to the Department of Health and Human Services, is widely under-diagnosed, caused approximately 122,000 deaths in 2004, making it the fourth leading cause of death.[13]  In 2002, the cost of COPD was $32.1 billion, a sum that has likely increased in recent years as the prevalence of COPD has increased.[14][15]  In 2006, 12 million adults were living with COPD, and the disease caused nearly 2 million emergency room visits and more than 660,000 hospitalizations.[16]  In addition, another 12 million Americans may have COPD but remain undiagnosed despite having symptoms.[17]

Diabetes.  Diabetes was the sixth leading cause of death in 2002, though studies indicate it may be under-reported on death certificates.[18]  Direct and indirect costs of diabetes were $174 billion in 2007.[19]  In the United States, 23.6 million people have diabetes, approximately eight percent of the population.[20]

Fortunately, prevention and wellness efforts could substantially reduce the incidence of chronic disease, contribute to healthier lives, and save money now spent on treatment.  For example, a recent study indicates that just a one percent reduction in adult smoking rates could result in 30,000 fewer heart attacks, 16,000 fewer strokes, and save more than $1.5 billion over five years.[21]  Another study found that the cost of heart disease treatment could be reduced by $5.6 billion if just 10 percent of Americans began walking regularly.[22]

Obesity

Increasing rates of obesity represent a challenge to our nation’s health, with more than two-thirds of American adults now classified as obese or overweight.[23][24] 

[Chart from CDC, available here]

In addition, approximately 17 percent of children and adolescents ages 2-19 are overweight.[25]  This high incidence of overweight children in the United States demonstrates the need to ensure that prevention and wellness are a pervasive part of American life, helping American children make and keep good nutrition and physical activity habits.

[Chart from CDC, available here]

Medical studies indicate that our nation’s high rates of obesity and overweight play a role in our battle with chronic disease; obesity and physical inactivity are identified as risk factors for more than 20 different chronic diseases, such as type 2 diabetes, heart disease, and some cancers.[26]  This association with chronic diseases drives up the cost of caring for obese and overweight individuals.  One study found that health care costs for obese workers were as much as 21 percent higher than for workers of a healthy weight.[27]  Another study found that obesity among Medicare beneficiaries doubled between 1987 and 2002, but the share of spending dedicated to treating obese beneficiaries tripled, jumping from 9.4 percent to 25 percent of total Medicare spending.[28]  

Part of addressing the obesity epidemic involves improving nutrition for American children and adults.  Healthy People 2010, an initiative of the Department of Health and Human Services, provides a framework for prevention for the United States, setting national goals regarding the most significant threats to public health and strategies to reduce those threats.[29]  Healthy People 2010 establishes a goal of 75 percent of the population consuming at least two servings of fruit each day, but for the 2003-2004 period, only 40 percent of Americans met this goal.[30]  Another target is for 50 percent of the population to eat three servings of vegetables each day, but only four percent of Americans met this goal in 2003-2004, a level unchanged from 1994-1996.  Clearly, we must do more to help Americans make the choice to eat more fresh fruits and vegetables, and we must help low-income communities and inner-city neighborhoods access affordable, nutritious food.  We must help children establish healthful nutrition habits, so they continue healthy eating into adulthood, avoiding the serious health problems associated with poor diet, such as heart disease, stroke, and type 2 diabetes.[31]

Tobacco Use

Tobacco is the leading preventable cause of death in the United States.[32]  Nearly 20 percent of American adults, or more than 43 million people, are addicted to cigarettes.[33]  Tobacco use kills more than 400,000 Americans each year, and an additional 50,000 nonsmokers die prematurely each year due to exposure to secondhand smoke.[34]  Americans’ health suffers from tobacco use, with 8.6 million Americans currently experiencing a smoking-caused illness.[35]

Smoking harms almost every organ in the body and is a contributing factor to many of the chronic diseases with which millions of Americans struggle.  For example, tobacco causes nearly 90 percent of all lung cancer deaths and at least 30 percent of deaths due to all types of cancer.[36]  Smoking also causes heart disease, the leading cause of death in the United States, and is responsible for 80-90 percent of all deaths from chronic obstructive lung disease.[37]

Health care costs for these individuals are staggering, with $96 billion in total annual public and private health care expenditures attributable to smoking.[38]  Estimates indicate that American taxpayers shoulder $68 billion of those costs due to expenditures made by Medicare, Medicaid, and other federal health programs.[39]  

In addition, our national economy experiences approximately $98.6 billion in productivity losses due to cigarette smoking and exposure to tobacco smoke, making the total economic burden of smoking approximately $192 billion per year.[40]   In contrast, in Fiscal Year 2007, the nation invested a mere $595 million in comprehensive, state-based tobacco prevention and control programs, 325-times less than the total economic burden of smoking.[41]

Studies show that state-based tobacco prevention and cessation programs are not funded at levels recommended by the Centers for Disease Control and Prevention (CDC).  For example, in Fiscal Year 2008, states spent less than three percent of the funds available to them from tobacco taxes and the Master Settlement Agreement (MSA) with tobacco companies on prevention and cessation programs.  If states invested just 15 percent of these funds on tobacco control programs, state programs would be funded at the level recommended by the CDC.[42]

Americans Support Investments in Prevention

According to a recent public opinion survey, more than three-quarters of Americans (76 percent) support increased investments in prevention programs to help people make healthier choices.[43]  Investing in prevention is popular across the political spectrum, with 86 percent of Democrats, 71 percent of Republicans, and 70 percent of Independents supporting investing more in prevention.

Support for More Investments in Prevention


Findings from a poll of 1,014 registered voters conducted by Greenberg Quinlan Rosner Research and Public Opinion Strategies from May 7 to 12, 2009.  The margin of error was +/- 3.1 percent.  Chart available here

The same survey found that investing in prevention is Americans’ highest priority for health reform, with 70 percent of Americans ranking investments in prevention between 8 and 10 on a scale from zero to ten (where zero means not at all important and ten means very important). 

Opinion on the Ability of Prevention to Save Money


Findings from a poll of 1,014 registered voters conducted by Greenberg Quinlan Rosner Research and Public Opinion Strategies from May 7 to 12, 2009.  The margin of error was +/- 3.1 percent.  Chart available here

Furthermore, Americans overwhelming believe investments in prevention will ultimately save us money, with 77 percent of respondents agreeing with the statement “prevention will save us money.”  As a further indication of the nation’s support for improved prevention efforts, 72 percent of respondents believe that investing in prevention is worth it even if it doesn’t save money, because of disease prevention and life saving benefits. 

Support for Investments in Prevention Regardless of Whether it Saves Money


Findings from a poll of 1,014 registered voters conducted by Greenberg Quinlan Rosner Research and Public Opinion Strategies from May 7 to 12, 2009.  The margin of error was +/- 3.1 percent.  Chart available here

Addressing Prevention and Wellness in Health Reform

Health reform must truly transform health care in America from a focus on treating and curing disease to a focus on preventing disease and staying healthy.  In order to increase use of preventive services already available, we must change the way health care providers are reimbursed for their services.  Current payment systems focus on volume of care over value, so that while physicians certainly have a personal interest in keeping their patients healthy, they have no economic incentive to provide the preventive services that will help their patients achieve that goal.

Health insurers also lack incentive to cover preventive services as part of a benefit package, because very few people maintain the same insurance coverage for any extended period of time, with the exception of Medicare beneficiaries.  Health reform must include insurance regulation reforms to provide health insurers with the necessary incentives to generously cover prevention and wellness services that will keep Americans healthy and keep health care costs under control. 

Health reform should also include an investment in evidence-based disease prevention programs that target behaviors that most influence an individual’s health and risk of contracting a preventable disease, such as physical activity, nutrition, and tobacco use.  One study found that a $10 per person investment in community-based disease prevention programs could yield health care cost savings of $16 billion annually within five years, and a return on investment of more than $6 for every $1 invested within 10-20 years.[44]  This estimate only includes health care cost savings, and does not take into account increased worker productivity and enhanced quality of life that would result from a reduction in chronic disease.    

Transforming our current “sick care” system into a real health care system is no small task, but a new focus on and investments in prevention and wellness policies will reduce the number of Americans suffering from chronic disease, reduce health care costs, and help more Americans live long, healthy, and productive lives.



[1]      Centers for Medicare and Medicaid Services, “National Health Expenditures 2007 Highlights,” accessed 6/10/09,  available here.

[2]      J.M. Lambrew, “A Wellness Trust to Prioritize Disease Prevention,” April 2007, available here.

[3]      Trust for America’s Health, “A Healthier America: Top Ten Priorities for Prevention,” March 2008, available here.

[4]      E. McGlynn et. Al., “The Quality of Health Care Delivered to Adults in the United States,” 2003, New England Journal of Medicine.

[5]      R. DeVol and A. Bedroussian, et al.  “An Unhealthy America: The Economic Burden of Chronic Disease,” October 2007, available here.

[6]      Centers for Disease Control and Prevention, “The Burden of Chronic Diseases and Their Risk Factors: National and State Perspectives 2004,” 2004, available here.

[7]      Centers for Disease Control and Prevention, “The Burden of Chronic Diseases and Their Risk Factors: National and State Perspectives 2004,” 2004, available here.

[8]     Centers for Disease Control and Prevention, “Chronic Disease Overview,” last modified November 20, 2008, available here.

[9]      American Heart Association, “Heart Disease & Stroke Statistics 2009 Update At-A-Glance,” 2009, available here.

[10]   American Heart Association, “Heart Disease & Stroke Statistics 2009 Update At-A-Glance,” 2009, available here.

[11]    American Cancer Society, “Cancer Facts and Figures 2009,” accessed 6/10/09, available here.

[12]    American Heart Association, “Heart Disease & Stroke Statistics 2009 Update At-A-Glance,” 2009, available here.

[13]    Public Health Service, U.S. Department of Health and Human Services, “Progress Review: Respiratory Diseases,” May 22, 2008, available here.

[14]    Center on an Aging Society, Georgetown University, “Data Profile: Chronic Obstructive Pulmonary Disease,” November 2002, available here.

[15]    American Thoracic Society, “COPD Will Cost U.S. $800+ Billion Over the Next 20 Years, Study Predicts,” 2006, available here.

[16]    Public Health Service, U.S. Department of Health and Human Services, “Progress Review: Respiratory Diseases,” May 22, 2008, available here.

[17]    National Institutes of Health, “New Survey Suggests Growing Awareness of COPD, Nation’s Fourth Leading Killer,” November 13, 2008, available here.

[18]   Public Health Service, U.S. Department of Health and Human Services, “Progress Review: Diabetes,” October 20, 2006, available here.

[19]    American Diabetes Association, “Direct and Indirect Costs of Diabetes in the United States,” accessed 6/10/09, available here.

[20]   American Diabetes Association, “Diabetes Statistics,” accessed 6/10/09, available here.

[21]    J.M. Lightwood and S.A. Glantz, “Short-Term Economic and Health Benefits of Smoking Cessation – Myocardial Infarction and Stroke,” 1997, Circulation.

[22]   B. Bulwar, “Sedentary Lifestyles, Physical Activity, and Cardiovascular Disease: From Research to Practice,” December 2004, Critical Pathways in Cardiology 3, no. 4: 184-193.

[23]   Centers for Disease Control and Prevention, National Center for Health Statistics, “Prevalence of Overweight and Obesity Among Adults: United States, 2003-2004,” April 2006, available here.

[24]   Public Health Service, U.S. Department of Health & Human Services, “Progress Review: Nutrition and Overweight,” April 3, 2008, available here.

[25]   Centers for Disease Control and Prevention, National Center for Health Statistics, “Prevalence of Overweight Among Children and Adolescents: United States, 2003-2009,” April 2006, available here.

[26]   Centers for Disease Control and Prevention, “Preventing Obesity and Chronic Diseases Through Good Nutrition and Physical Activity,” revised August 2008, available here.

[27]   E. Ostbye, et al, “Obesity and Workers’ Compensation: Results for the Duke Health and Safety Surveillance System,” 2004, Archives of Internal Medicine 167, no. 8.

[28]   K. Thorpe and D. Howard, “The Rise In Spending Among Medicare Beneficiaries: The Role of Chronic Disease Prevalence and Changes in Treatment Intensity,” 2006, Health Affairs, 25, no. 5. 

[29]   U.S. Department of Health and Human Services, “About Healthy People,” accessed 6/10/09, available here.

[30]   Public Health Service, U.S. Department of Health & Human Services, “Progress Review: Nutrition and Overweight,” April 3, 2008, available here.

[31]    Public Health Service, U.S. Department of Health & Human Services, “Progress Review: Nutrition and Overweight,” April 3, 2008, available here.

[32]   Trust for America’s Health, “Blueprint for a Healthier America,” October 2008, available here.

[33]   National Center for Health Statistics, 2007 National Health Interview Survey

[34]   Centers for Disease Control and Prevention, “Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses – United States 2000-2004,” MMWR 57(45), November 18, 2008, available here

[35]   Centers for Disease Control and Prevention, “Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses – United States 2000-2004,” MMWR 57(45), November 18, 2008, available here

[36]   American Cancer Society, “Cancer Facts and Figures 2008,” accessed 6/10/09, available here.

[37]   Trust for America’s Health, “Blueprint for a Healthier America,” October 2008, available here.

[38]   Centers for Disease Control and Prevention, “Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses – United States 2000-2004,” MMWR 57(45), November 18, 2008, available here

[39]   Campaign for Tobacco-Free Kids, “Toll of Tobacco in the United States of America,” April 1, 2009 available here

[40]   Centers for Disease Control and Prevention, “Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses – United States 2000-2004,” MMWR 57(45), November 18, 2008, available here

[41]    Centers for Disease Control and Prevention, “Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses – United States 2000-2004,” MMWR 57(45), November 18, 2008, available here

[42]   Trust for America’s Health, “Blueprint for a Healthier America,” October 2008, available here.

[43]   Greenberg Quinlan Rosner Research and Public Opinion Strategies for Trust for America’s Health and the Robert Wood Johnson Foundation, “Americans Rank Prevention as Most Important Health Reform Priority,” May 18, 2009, available here.

[44]   Trust for America’s Health, “Prevention for a Healthier America: Investments in Disease Prevention Yield Significant Savings, Stronger Communities,” February 2009, available here.

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