The historic health care bill that became law in March contains many important reforms, but perhaps none as significant as the Prevention and Public Health title. Its aim is to transform America’s current sick care system into a genuine health care system, one that is focused on keeping us healthy and out of the hospital in the first place.

The title includes a broad array of provisions, from eliminating co-pays for essential screenings and annual physicals to providing reimbursement for proven, cost-effective preventive services such as cancer screenings, nutrition counseling and smoking-cessation to expanding prevention efforts that occur in our communities. It is a landmark investment that finally puts an emphasis on keeping people healthy, instead of just treating them after they get sick.

It also addresses head-on the growing threat of childhood obesity. We are currently in danger of raising the first generation of Americans who will live sicker and die sooner than their parents. This is a public health crisis of the first order, and by partnering with the private sector we have some up with simple, reasonable strategies to address it. Posting calorie content on menus, for example, helps give parents more information and control over what their kids consume. And, in an effort modeled after a provision in the Prevention title, UnitedHealth Group is partnering with the YMCA to reimburse participants in the Diabetes Prevention Program, a 16 session, group-based lifestyle intervention for individuals at high-risk of developing Type 2 diabetes. These efforts add up to real improvements in our public policy and public health, and they start in the community -- where investments in prevention can have the most value.

Preventing disease isn’t just the right thing to do – it’s the smart thing to do. Consider this: right now, the bulk of health care costs are accounted for by conditions that are largely preventable and even reversible by changes in nutrition, physical activity and lifestyle. By focusing on prevention, we can start to bend the cost curve down, improving our physical and fiscal health for generations to come.

Ellen-Marie Whelan, NP, PhD is a senior health policy analyst and associate director of health policy at the Center for American Progress. Here's what she has to say:

"One out of every three children in the United States is obese or overweight, putting them on a path to become obese adults. This epidemic is making our children sicker. The number of hospitalizations for children due to obesity-related conditions nearly doubled between 1999 and 2005. But it’s not just the kids, if we follow this trajectory into the adult population, obesity is to blame for many of the most common of chronic illnesses—which account for an estimates 83 percent of all U.S. health expenditures—and ends up costing the nations hundreds of billions of dollars each year in direct medical costs, absenteeism, and decreased productivity.

"The new Patient Protection and Affordable Care Act includes quite a few programs that could help. But the bottom line is that we have to prevent obesity before it occurs, which is why we must focus on our children. If we don’t, this generation of children could be the first to have shorter, less healthy lives than their parents.

" The first thing we have to do is support, encourage, and invest in what we know works to prevent obesity. For example, need to promote breastfeeding, help families prepare healthy meals at home, and encourage better primary care.

• Promote breastfeeding: Research estimates that we could prevent 15 to 20 percent of obesity through breastfeeding. If we could get 90 percent of new mothers to breastfeed their babies for the first six months of life—which is a stretch—it could prevent over 900 infant deaths and save the nation at least $13 billion each year, including $592 million due to childhood obesity alone.

• Help families prepare healthy meals at home: The average American child consumes one-third of their calories from eating out. And each time they eat out, children eat almost twice as many calories compared to when they eat a meal at home.
• Encourage better primary care: Primary care providers must have time with families to talk about obesity prevention during scheduled office visits. We should maximize use of community health workers and nursing home vitiation programs that can provide more culturally sensitive teaching.

" We also need to know more about the big problems we don’t know much about. For instance, what is causing infants to become obese? A Harvard study found that the number of overweight babies under 6 months old increased 74 percent from 1980 to 2001. This cannot be blamed on McDonalds and Twinkies. Findings like this have caused many to wonder about the relationship between environmental chemicals and obesity—now known as “obesogens.”

" One of the major limitations in obesity prevention is better understanding what works to prevent obesity and—even more difficult—losing and keeping weight off. We still cannot provide a clear pathway for obese individuals despite years of investigation. PPACA establishes a number of research-related provisions that must be coordinated with ongoing efforts at NIH, EPA, and other entities examining this epidemic.

"We also need better monitoring data that describes the obesity epidemic so that the American people and the health research community stay better informed on the progress of efforts to tackle the epidemic. This does not necessarily mean collecting more information—just making sure the data we collect is uniform and in a format that allows comparison to other data sources.

" Successfully tackling childhood obesity will require a long-term, large-scale commitment that combines individual responsibility and action together with community-based approaches. But prevention is the key. Passage of the Affordable Care Act is a good first step that will help promote the health and well-being of our children and our society, and the fiscal health of our nation."

This question will be the source of many lively debates as we begin to implement PPACA. Research shows that as a society, we have an overriding feeling of contempt for those who are overweight and obese. We show it in a variety of ways, from looks of horror on the street, to job and wage discrimination. We need to get our collective heads out of the sand and try to aggressively respond to the tsunami bearing down on us.

Obesity is one of the most serious adverse health conditions in the United States today, and is the major driving force behind increased rates of chronic diseases like diabetes and coronary heart disease.

Obesity is truly an epidemic. In fact, recent research by Ken Thorpe finds that over 40% of all Americans will be obese by 2018, and spending attributable to obesity will more than quadruple. More than 20% of all U.S. health care dollars will be spent on obesity. Yes, you DID read that correctly: in 8 years, 1 out of every 5 health care dollars will be spent on obesity.

Think about the implications. Not only will our health care system be weighed down, but the impact on our workforce and productivity will be profound.

There are some clear and achievable goals we can embrace. According to the NIH’s National Heart, Lung, and Blood Institute modest weight loss of 5-10 percent can help mitigate high blood pressure, high blood sugar, and high cholesterol. In this case, slow and steady leads to the best results.

And as anyone who has ever tried to lose weight knows, weight loss is only the first step. Maintaining that weight loss may be the hardest part of the journey. In order to acheive sustainable weight loss, investment in primary prevention is essential.

We must begin viewing obesity in the United States as a serious health condition with serious consequences rather than simply an undesirable physical attribute. We will fail miserably at improving US health and productivity outcomes without an environment that promotes maintenance of healthier weight.

The tsunami is coming. We have a limited amount of time left to prepare. Unless we move beyond the rhetoric it is going to crush both our health care system and our workforce. It’s time to stop fighting and start moving.

I don’t think there is any question that preventive care, wellness programs, and early diagnosis and treatment are valuable and that our system needs to move much more in this direction than in continuing to pay more and more to treat people after they become acutely ill.

Nonetheless, I am concerned that the health overhaul law will curtail many of these programs that are already showing positive results. The law will lead employers to focus more on following the rules set by Washington than in continuing to develop and enhance programs with demonstrated success in coordinated and integrated care, including prevention. Just tacking screening tests onto an insurance policy will not get us to the goal of a more efficient health sector that engages patients as partners in managing their health care.

Instead as John Goodman points out, Health Savings Accounts (HSAs) – and other consumer-driven plans – provide incentives for preventive care. They get people more involved in their health care, provide incentives for them to get the best value for their health care dollars, and encourage people to seek out information on quality and price.

Preventive care is most likely to save money and be successful when it is integrated into coordinated care programs that engage patients as partners in their health spending and health care. Smoking cessation medications are most successful if integrated into educational and support programs. Some companies provide diabetics with supplies and medications at no cost if they make monthly visits to care coordinators who can detect early signs of the progression of their illness. Treatment must go beyond providing the medicines to include treatment for secondary issues such as pain and cardiovascular disease in a system of care. Cholesterol-lowering drugs are most likely to be effective when they are combined with a program of diet and exercise. Many private employers and health plans provide incentives for this integrated, coordinated care.

Investments in preventive care are valuable and humane. They save lives and can enhance productivity by treating patients early so they can get back to their jobs and families. But even the Congressional Budget Office says, “[T]he evidence suggests that for most preventive services, expanded utilization leads to higher, not lower, medical spending overall … Researchers who have examined the effects of preventive care generally find that the added costs of widespread use of preventive services tend to exceed the savings from averted illness.”

The first thing we need to clear up is what is meant by prevention. Too many, including John Goodman and much of the press, defiine prevention simply as disease detection (secondary prevention). These preventive efforts include cancer and other screenings and are intended to detect disease earlier to allow more effective clinical interventions that could improve the quality and/or longevity of life. They are not fundamentally intended, and never have been, to save money.

Two other forms of prevention do save money and its here we need to invest. The first, primary prevention efforts to reduce smoking and weight when appropriately designed can save money, and improve clinical outcomes. A national randomized controlled trial showed that the diabetes prevention program--a specific diet, exercise, nutrition and educational intervention targeting overweight prediabetic adults reduced the incidence of diabetes by 58%. This is compared to a 24% reduction (relative to placebo) for metformin, a proven medication designed to regulate blood sugar levels. The DPP has been adopted in community based settings such as the YMCA and cost 15% of the original protocol. As a result, this program saves money within 2 years. Its a major factor in why United Healthcare has added this to their plan offerings. The CDC should invest a significant amount of its wellness budget in scaling and replicating these interventions nationally. They have been shown through clinical trials to reduce diabetes incidence and more recently to save money--a great combo.

The other form of prevention is tertiary prevention--designed with work with chronically ill patients to keep them from having complications associated with their conditions and ending up in the hospital clinic or ER. Lets take just one element of a well designed program--transitional care. Today, 20% of Medicare patients are readmitted to the hospital within 30 days--these are preventable ( Medpac has estimated that 80% of such readmissions are potentially preventable). Since Medicare has no care coordination in the traditional FFS program, this is not a huge surprise. Transitional care programs as evaluated using randomized trials at U Penn and Colorado have shown that readmissions such as these can be reduced by over 50%. For Medicare, the cost of these readmissions over the next decade totals $250 Billion. Investing in community health teams (section 3502 of the Senate bill) that include transitional care programs would result in a very substantial return on investment, one that CMS should be gearing up to start next year.

So investintg in evidence based primary prevention and effective tertiary prevention efforts will not only save money but improve clinical outcomes.

The National Institutes of Health has numerous institutes, mainly devoted to the study of basic mechanisms of disease leading to better treatment and prevention. Our belief is that if we used the prevention and wellness money to create an additional institute, the National Institute for Keeping People Healthy, dedicated to keeping people healthy even with the presence of a chronic disease, we could reduce the amount of health care dollars spent on end of life care by reducing chronic disease.

Two weeks ago, the Journal of the American College of Cardiology (JACC) released a report titled “Our Physicians and Our Profession Must Lead in Improving Our Health Care System.” I had the pleasure of co-authoring the report with Dr. Tim Garson of the Office of the Executive Vice President and provost at the University of Virginia, and Carolyn Engelhard, MPA with the Department of Public Health Sciences also at the University of Virginia.

In it, the ACC calls for a National Institute for Keeping People Healthy (NIKPH), this would be designed to lower the cost of health care delivery over the long run.

You can read our article in its entirety here.

Our health care costs are increasing because we have succeeded in keeping people alive but have not yet succeeded in keeping them healthy. Much has already been done to combat the obesity epidemic, including the First Lady’s program aimed at fighting childhood obesity, but more can be done at the Federal level.

Today, almost 44 percent of Americans have one or more chronic conditions. We spend 10 percent of all our medical care dollars in the last year of life, and the longer we live, the more expensive it will be to die because the growth in medical care inflation continues to outpace baseline inflation.

The U.S. Preventative Services Task Force can do more to promote a strong relationship between doctors and patients by funding this much-needed institute. The patients who are the healthiest are the ones who maintain strong contact with their physicians and take part in making decisions about their overall health care management. The funds to encourage prevention and wellness measures provided in the new health care reform legislation would be a good first step in bending the cost curve by keeping people healthy.

It is too bad that the new health reform law will require all insurance to cover preventive services with no cost sharing. This is the exact opposite of sound policy. With few exceptions (e.g., childhood immunizations), third party insurance should not pay for these services at all. Instead, patients should make their own decisions, managing their own health care dollars in a Health Savings Account.

The reasons: (1) there is overwhelming evidence that preventive care adds to total health costs rather than reducing costs, so there is no legitimate third-party interest in subsidizing this kind of care; (2) this is the type of expenditiure where patients can save considerable money through careful shopping (by using walk-in clinics, for example); (3) the experts differ on when, how much and how frequently patients should have these things done, as almost any daily newspaper will confirm, and (4) since patients differ in their attitude toward health care in general and risk in particular, this is precisely the type of activity where individuals should make their own decisions and we should be willing to let different people make different choices.