A recent study from the Robert Wood Johnson Foundation suggested that in the cost-benefit analysis of various public health interventions, we may need to expand the timeframe we use when determining the benefits half of the equation. Instead of evaluating over a 10-year period, we need to understand that the true benefits of these types of long-term initiatives are sometimes not seen for up to 25 years. Only by analyzing a period that long will we understand the real impact of prevention.
As I reviewed the study, I could just see the rolling eyes of detractors who make it so difficult to support and fund prevention efforts. Because despite its importance, our nation of “I need it yesterday” and “instant satisfaction” has such a hard time with any effort that takes longer than our attention span to prove itself.
A doctor’s dilemma
This attitude is why I, as a physician, can bill my patients insurance for bariatric surgery, but can’t bill for counseling patients about behaviors that might help them prevent the need for bariatric surgery. This attitude is why my patients can’t book an appointment to talk about practical and doable steps they can take with their families to prevent them from transitioning from unhealthy people who can make slow, steady changes to people who need costly interventions of last resort.
This attitude is the underlying reason why, by contrast, they can get the intervention of last resort: surgery. (A recent change in Medicare will allow for obesity screening and behavioral counseling in the care of obese patients, and maybe someday, the results of that pilot will pave the way for wider adoption of these preventive efforts, but for now, the last resort is sometimes the only one.)
A mom’s frustration
The impulse toward immediate gratification is why as a parent, I’ve recently found my efforts to provide a healthier snack option for my child thwarted. My daughter’s extracurricular class agreed to let me provide healthier snacks for the kindergarten students as a pilot. This worked for three weeks with rave reviews from kids and parents alike. The principal was totally on board, and even agreed to send home a letter I wrote that included the reasons for the change plus healthy tips to try at home. But this past week the kindergarten teachers heard the upper classes were getting pizza (you know, for that meal between lunch and dinner that happens at 2:30 pm), and revolted because they wanted pizza, too. The administration faced a choice:
- Option 1: Deal with the teachers who feel deprived and explain that we’re working on an initiative that’s going to play a role in kids and families’ future health.
- Option 2: Please people in the short term.
I won’t spell the story out in full detail; let’s just say that last week, everybody got pizza.
The staggering cost: From $3 to $147 Billion
Time and again, we want the quick fix. And to be sure, many families aren’t doing the true cost-benefit analysis when they’re trying to put out the fire of a hungry family for the money in their pocket. The deck is stacked against them. Foods provided at artificially low prices are often highly processed, unhealthy, and lack the nourishment of more expensive options. And the kind of “free market” we’ve created – one in which the inflation adjusted price of sugar sweetened beverages has dropped 35% since the 1980s while fruit and vegetable prices have increased by the same amount – doesn’t help.
But the complex and compounded reality is different: The calorie-busting fast food that costs $3 today tallies up (in the long run) to $147 billion dollars per year of medical care costs for overweight and obese patients suffering from the morbidities that cheap, quick calories lead to.
So yes, if we want sustainable and meaningful changes in health, we’re going to have to slow down and wait for the results that really matter – not a popular option in our society of get-there-before-you- leave-here and multitasking-till-you-drop-to-get-it-all-done-before-it’s-due.
And on top of that, we’re going to have to understand that until people have the honest information they need to make well-informed decisions, “free markets” aren’t free – they’re actually pretty costly for those who have the least to spare.
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