The Argument for Prevention

Amid competing cries of triumph and consternation—along with some grunts of cynicism—health care reform in America will become reality. Scholars, journalists and politicians have together acknowledged the significance of the Health Care Bill, passed through the U.S. House of Representatives on March 21st as the Reconciliation Act of 2010. The package represents the culmination of a century’s worth of efforts to establish a system of universal health care in the U.S., a vision whose roots are frequently attributed to Teddy Roosevelt, and an ideal that had been famously championed by FDR, LBJ, Ted Kennedy and Bill Clinton.

Perhaps less frequently acknowledged were the efforts of Presidents Truman and Kennedy; both men sought to implement health care reform through a comprehensive, federally subsidized system. Even Nixon fought for universal coverage, entering into negotiations with spokespeople of Senator Kennedy in 1971 to resolve differences between Republican and Democratic proposals. Yet despite decades of soaring costs, burgeoning gaps in coverage for individuals with medical conditions, wide ranging, class-based disparities in services, and shrinking reimbursements to physicians, it has taken until 2010 for broadband change to be realized.

There is much in the present legislation to be grateful for. Pertinent to the administration of care for those who need it most—for people experiencing poverty and homelessness, for the elderly, for the chronically ill, for pregnant women and children—are several key provisions. For Massachusetts, these include a $2 billion increase in Medicaid funding over 10 years, subsidies for an estimated 75,000 moderate income residents to pay premiums, new taxes on expensive plans and on the investment income of wealthy residents, and the closure of the Medicare “donut hole” for prescription drugs, according to a summary published in the March 22nd edition of the Boston Globe. For areas of the country beyond the borders of the Commonwealth, which do not currently enjoy systems of universal coverage, differences will be notable and affect tens of millions of Americans.

Yet whether contemporary health care reform will precipitate a true paradigm shift in the way in which wellness is popularly envisioned in the United States remains dubious. Presently, the dominant medical model conceptualizes health based on lack—that is, the absence of disease. When illness is not present in a patient, the role of the health care provider is minimal. The services of physicians, nurses, and therapists are valued according to their ability to transform sickness into health. Less emphasized, and more difficult to achieve insurance reimbursement for, is preventive care: fostering health even in the absence of illness.

Many critics of the extant American health care system (or as some would argue, the lack thereof) decry the skyrocketing cost of contemporary medical treatment. Many voices have blamed diverse sources for excessive expense. Some accuse health insurance corporations of greed and monopolistic intent; others fault hospitals for pushing expensive tests and procedures; still others seek to castigate physicians themselves, griping about rates and salaries. Rarely is the underlying culture of health and well-being that exists in the U.S. questioned. Voices that critique the Western medical model as overly focused on pathology are rarely taken seriously—at best, alternatives are regarded as novelties to be assimilated or as diversions to flirt with until something really goes wrong.

Now, it is not my intent to propone the abolition of the practice of industrialized medicine. It is difficult to argue with the positive effects that enlightened understanding of disease etiology and treatment has produced worldwide. I would hope to praise rather than undermine efforts to combat HIV and AIDS, cancer, malaria, and other deadly viruses and conditions, especially among populations of meager resources. But I also believe that variables such as health consciousness and perception of well-being are critical to the prevention of illness on an epidemiological scale.

Several prominent health care organizations have backed the practice of preventive medicine as a crucial means through which to mitigate pathology, thereby cutting associated health care costs. Among these is the World Health Organization (WHO), which in 2008 published a fact sheet entitled “Integrating prevention into healthcare.” In this document, the WHO stated, “Many diseases can be prevented, yet health care systems do not make the best use of their available resources to support this process. All too often, health care workers fail to seize patient interactions as opportunities to inform patients about health promotion and disease prevention strategies.” The Organization elaborated its vision for an increased focus on prevention by invoking the need for financing of systems and policies that support preventive medicine, as well as making prevention an element of every interaction associated with health care.

President Obama’s 2010 Proposal for Health Care Reform included support for preventive medicine. Specifically, Title IV of the proposal, “Prevention of Chronic Disease and Improving Public Health” stated, “The Act will promote prevention, wellness, and the public health and provides an unprecedented funding commitment to these areas. It directs the creation of a national prevention and health promotion strategy that incorporates the most effective and achievable methods to improve the health status of Americans and reduce the incidence of preventable illness and disability in the United States.” Clearly, the White House had considered a paradigm shift towards a culture of enlightened and empowered well-being to be a significant priority.

Yet the landmark Health Care Bill, in its most recent iteration as the H.R. 4872 legislation that passed in the U.S. House of Representatives on March 21st, did not include any concrete strategies for health promotion. Neither funding nor resources allocated for preventive care are represented in the federal reform measure. In fact, the term “prevention” does not appear once in the more than 20,000 word document.

It therefore appears that any widespread re-evaluation of health consciousness that would orient the nation towards values of education, empowerment of individuals to make healthy lifestyle choices, and the supposed augmentation of disease prevention that should result, will not be directly precipitated by health care reform at the federal level. Instead, it may be necessary for we as health care consumers to take matters into our own hands.
The President’s original proposal had declared, “The Act relies on the innovation of small businesses and state and local governments to find the best ways to improve wellness in the workplace and in our communities.” At present, it appears that such innovation will not be directly subsidized by federal funds in the prospective environment of reformed health care in America.

Nevertheless, as individuals we can promote healthy living in myriad ways. Most significantly, we can set good examples by practicing healthy lifestyle habits. The formula is nothing new—eat a balanced and relatively low-calorie diet, exercise regularly, quit smoking, drink in moderation if at all, engage in safe sex and other pleasurable activities, etc. Of course, it should not be forgotten that many of these individual-level prevention strategies are more easily supported by middle-class incomes, and that situations of poverty make maintaining physical and psychological health more difficult. So, if you can afford to live well, help others to do so too. Purchase healthy food for donations. Give older or unused exercise equipment to low-income families or to charities equipped to distribute such goods. Lobby for the preservation of open spaces like parks and nature preserves where people of all backgrounds can congregate free of charge.

When the dust surrounding the debate over the Health Care Bill settles, new directions for the conceptualization of well-being will likely be more clearly established. Ultimately, reform is not solely encapsulated in legislative measures—instead, change is enacted through the practices of people. In order for prevention to be culturally actualized on a pervasive level, health must be valued as the presence of wellness, rather than as the absence of disease.