There are different levels or categories or “tactics” that can improve population health – in our last blog we discussed those that fall into the realm of tertiary and quaternary prevention, and in our current system, the ones that are most likely to give us the quickest “bang for the buck”. But what about primary and secondary prevention that fall more squarely into the domain of public health interventions? We often hear that we don’t spend enough money on public health efforts even though they save lives and reduce costs – so why are those funds often the first to get cut when governments implement austerity measures?
A 2013 JAMA editorial does a very nice job outlining the “paradox of prevention” – we all know it’s good for us, yet the long time horizon of reaping the benefits of primary and secondary prevention, often coupled with the need for consistent behavior changes (and other factors), make this type of prevention a bit of a hard sell when it comes to influencing individuals in a population. Moreover, the case for stronger emphasis on and investment in prevention is further complicated by the mixed data on the cost savings and cost-effectiveness of public health interventions. The overarching conclusion has been that yes, public health interventions improve health outcomes, but when it comes to reducing costs, not always. The biggest ROI for public health efforts seems to have come from interventions that require little to no cooperation, personal responsibility, or any actual awareness from citizens (e.g., sanitation, clean drinking water, “sin” taxes), with diminishing returns as the degree of individual decision making required to for the intervention to succeed increases (e.g., health promotion efforts to reduce obesity).
Moreover, while improvements in the average health of the population can lower healthcare spending per capita in the short-term, there is growing recognition that the resulting longer life span will inevitably generate additional costs, due to both higher healthcare needs and retirement benefits. This is a particularly important issue in our “pay-as-you-go” system of Medicare and Social Security, both programs already bursting at the seams and with a growing number of beneficiaries supported by an ever-dwindling workforce. That we are living longer and have the possibility of expanding our lifespan further is a gift, yet programs that serve the elderly do not reflect changes in life expectancy or the growth rate of healthcare costs vs. employee wages.
One way to offset the cost implications, while reaping the benefits of the longer lifespan brought about by preventive measures, may be by raising the full eligibility age for Medicare and Social Security. This would allow for additional federal revenue to accrue from healthier people remaining longer in the workforce. In the case of Medicare, for example, seniors would still have the option of claiming eligibility at 65, but would receive fewer benefits than if waiting until the new full eligibility age threshold is reached (e.g., 69 years) – akin to what is already being implemented for Social Security. Finally, raising the age of full eligibility will not only help close the Medicare and Social Security funding gaps, but would also encourage seniors to build up adequate retirement savings, which will help boost the nation’s overall economy.