Does Prevention Really Cut Health-Care Costs?

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If you’ve been trying to follow the debate over U.S. health-care reform, you might be confused about whether Obama’s plan is really going to cut costs, how much it will save, and how on earth there can be so much debate over what seems like accounting. At the heart of this issue, however, is the question of prevention: Can prevention really cut health-care costs?

At first blush the answer seems obvious. If I don’t need a new heart stent, then no one has to pay for it. But the question becomes more slippery when you start to look at life-time health costs. We’re all going to die eventually — there’s no preventing that — and that means it’s hard to prevent the period of very poor health that comes right before death — a period which tends to be very, very expensive.

In 1997, a group of scientists at Erasmus University in Holland famously showed that smokers have lower total life-time health-care expenditures than non-smokers. Smokers do cost a lot more per year of life, but because their lives are so much shorter on average, the non-smokers end up with higher costs in the long run. Recently people have started to make a similar argument about obesity: that overweight people will cost less overall because they don’t live so long. I have yet to be convinced of this. Obesity causes all kinds of expensive disability, driving up costs per year of life, while in fact the link between excess weight and early death is surprisingly weak. But the point here is that it’s not impossible for prevention — prolonging life, and even prolonging healthy life — to lead to higher health-care costs overall.

So does prevention cut costs? It turns out that the answer really can depend on how you’re counting. The authors of the 1997 paper about smokers’ health found that eliminating smoking would have cut costs in the short run — for about 15 years — even as long-run expenditures increased because people were living longer. Similarly, if we’re willing to assume for minute (and I’ll suspend my disbelief) that obesity, like smoking, actually cuts a person’s life-time health costs because it cuts his or her lifespan, we could still probably decrease each person’s current health-care costs by preventing obesity-related illness today. (If we don’t assume that obesity is like smoking in this respect, then preventing obesity-related illness will cut costs both now and in the future.)

Finally, the accounting of prevention is complicated because it’s not all that clear how to calculate the benefit side of the cost-benefit calculation. A person who dies in a car crash at age 18 will have far lower lifetime health-care costs than someone who dies of heart disease aged 82. But the 18-year-old also contributes far less in lifetime taxes or in insurance premiums, so it’s tough to say whether he or she might have cost less, on balance, by living longer. And that person’s life was also cut tragically short. There must be some benefit simply to living in good health, after all. Who wouldn’t pay some token sum now to avoid, say, dementia or diabetes in the future? (If you’re interested in tips for your own life, you can check out TIME’s recent prevention special here.) In the end it seems that, as with so many things in politics, all sides of the health-care debate will find a fact or two to support its case.