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Evan Horowitz

The health care debate we should be having

There’s something wrong with our health care debates. Always in D.C., the big questions are about insurance: who has it, how they get it, how much the government should pay.

But even the most comprehensive insurance can’t help if nearby doctors are too busy to see you. Or if the water flowing from your tap is full of lead. Or if the only affordable food is stuffed with junk calories.

The health measures we care most about — our lifespans, the quality of our years — are shaped by forces far removed from any doctor’s office. Like our eating habits, our commutes, the care we got as children (or in the womb), the availability of quality education, and a great deal besides.


Most of the life expectancy gains of the last century can be chalked up to what we call public health, a catch-all term for those interventions aimed not at a single patient, but at a whole community or the entire population. Think sewage treatment and cigarette taxes, not new pills or breakthrough surgical techniques.

And yet, public health interventions get a piddly share of attention, not to mention scant government funding. Which helps explain the great riddle of American health care: How come we spend more than everyone else, yet generally have worse outcomes? We overspend on medical care and underinvest in public health.

How to fix that imbalance and optimize our limited health dollars? That may be the health care debate we really need to have.

The best bang for the health care buck

It’s a hot research topic, figuring out which public health interventions will add the most quality-years to American lives, at the lowest cost.

Antismoking campaigns remain the gold standard. In the United States, the smoking rate was cut in half and some 8 million early deaths averted by a combination of warning labels, age restrictions, cigarette taxes, limits on advertising, and funding for smoking cessation programs.


Looking ahead, the idea would be to replicate the multipronged antismoking initiatives to address other public health scourges. Here are four of what researchers see as the most promising opportunities — along with a surprising counterexample, something that doesn’t work as expected.

Reducing obesity. When the whole planet is getting heavier, you can’t blame individual willpower. Fighting the obesity epidemic would mean taking on systemic causes like the plenitude of cheap, nutrient-poor food and automobile dependency. Perhaps we should start with a sugar tax, or direct funding to help families provide healthful childhood nutrition. If that seems like a tall task, well, so was tackling nicotine addiction. A 50 percent reduction in adult obesity could save an estimated $58 billion in medical costs every year.

Lead abatement. Even in small doses, lead is a terrible poison, damaging the brain in ways that permanently affect intelligence and also increase the propensity to commit crimes. As the crisis in Flint, Mich., reminded us, there’s a lot of lead left in America. Removing it from houses, water lines, and soil would take a fair bit of up-front money, but the payoff could be enormous. By one estimate, every dollar spent to get rid of lead paint returns $17 to $221 in benefits, thanks to increased education and reduced violence.

Zero traffic fatalities. Nations around the world and cities across the United States (including Boston) have been redesigning streets and road rules with the goal of eliminating all vehicular deaths. That may sound a little pie-in-the-sky, but car accidents are among the leading causes of death for children and young adults, so cutting down on accidents could make a big difference in terms of extending lives.


Safe housing. This one may seem far removed from the world of health care, but few public health interventions are as research-proven. It’s also one of the areas where US government spending falls furthest behind, compared with the more generous housing benefits and social housing approaches found in Europe. Ensuring proper ventilation can reduce the risks of asthma, and consistent living arrangements help those struggling with mental illness and chronic homelessness.

End unnecessary tests. Good public health research, however, doesn’t just identify what works. It also exposes efforts that fall short. Take medical screening tests, the kind you endure every few years or when you reach a certain age — symptoms or no symptoms.

The idea seems sound: catch dangers early and treat them before they develop. And a few screening tests, like colonoscopies, really do seem to save lives. But too often, preventive tests end up identifying dangerous-looking things that would never have become a problem, leading to unnecessary testing and treatment. Which is why expert panels have stopped recommending regular stress tests, routine PSA prostate exams, and annual pap smears.


Public health requires public money. We have it.

While the best public health interventions offer great returns in the form of improved-health-per-dollar-spent, they still require up-front dollars.

Here the United States has one big advantage. Our medical spending is so inefficient that we don’t really have to worry about a trade-off, or fret that shifting money toward public health will hurt patient outcomes at the doctors office.

We could, for instance, let Medicare negotiate drug prices and use the savings for antiobesity efforts. Or reduce costs by making it easier for foreign-trained doctors to practice in the United States. Or enforce the fines companies are supposed to pay when they fail to offer decent insurance.

This doesn’t even include win-win approaches, the kind that raise money and also improve public health. Like a sugar tax, or an increased levy on alcohol.

Bottom line, money need not be a fatal obstacle in the drive to boost public health spending and improve the quality and quantity of life for many Americans. But somehow we do have to shift the debate.

Public health priorities have been largely forgotten in our perpetual battle over insurance. Which is damaging, because while health insurance is undoubtedly important, the broader objective is to ensure that Americans everywhere have the chance to enjoy long and healthy lives. Reaching that forgotten goal means looking beyond the doctor’s office.

Evan Horowitz digs through data to find information that illuminates the policy issues facing Massachusetts and the United States. He can be reached at Follow him on Twitter @GlobeHorowitz