Doesn't the "standard argument fail to account for integrated productivity over lifespan? Consider a heavy smoker who works and pays taxes for 20 years, then dies slowly and expensively. Contrast with a healthy worker who has a 40 year career, then suffers an equivalently expensive age related illness. There would seem to be a significant financial difference between these two cases.
Carried to the extreme, the "standard argument" would not see any difference between a society where everyone died at the age of 21 versus a society where everyone died at age 90. This seem patently ridiculous.

Loath vs. Loathe
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Good post.

You're underselling "medical technology utilization" as the primary cost growth driver, as it is most commonly viewed that way by most health economists that have studied the subject.

But analyses in this area are complicated and not straightforward as you suggest. Being healthier may lead to different, expensive ways of dying. But being less healthy undoubtedly impact our "bang for the buck" metrics compared to other countries. Our outcomes are the same or worse than other systems because our patients are starting from a sicker starting point (among other differences). Obesity, diabetes and cardiovascular disease unquestionably impact our use of health care, and a more mindful approach to healthy lifestyles would improve macro-level health outcomes while at minimum, maintaining cost.

Our health system isn't actually worse than Slovakia's, no matter how much Daschle implies otherwise.

Most, probably, of our decisions to do something positive, the full consequences of which will be drawn out over many days to come, can only be taken as a result of animal spirits — of a spontaneous urge to action rather than inaction, and not as the outcome of a weighted average of quantitative benefits multiplied by quantitative probabilities. Enterprise only pretends to itself to be mainly actuated by the statements in its own prospectus, however candid and sincere. Only a little more than an expedition to the South Pole, is it based on an exact calculation of benefits to come.

Shorter Keynes: stop pretending you are so rational. The world wouldn't function, much less progress, if we actually acted that way.

In this case, if the payoff from keeping diabetics healthy looks like it has any chance of coming close to, say, half of what it costs to chop off their limbs, we should do it. Because we all basically agree the point of society is to create a world where we live healthfully as long as possible. And this looks like it'll move the ball down the field, at a price we can all afford for what we're getting.

So we don't know for sure. So what? Government is allowed to invest, too. Besides, I thought we were a nation founded on a "grand experiment." Relative to that, this is a no-brainer.

Actually, when it comes to smoking, the data shows that it does lower overall health costs. Lung cancer is rather hard to treat. Most who contract it do not die "slowly and expensively," as Brian assumes in his comment above. The opposite is true. A higher percentage of smokers will die while they are still paying into the system, thus leaving more resources for their non-smoking friends--you know, the retirees who will live 2 or 3 decades after they retire, and will spend those decades drawing much more money out of the system than they ever put in.

You post reinforces one laughable point of healthcare reform. Those in charge think that magically, if we spend more on primary care and less on procedures, that instantly we are going to save money. Chronic management of Diabetes and Heart Disease are certainly not bang for the buck. They both typically have a QALY of nearly 150,000 dollars, while total joint replacement has a QALY as low as 5000 dollars. Since it doesn't fit into the specialist are evil and so are procedures diatribe, it gets brushed under the rug. No one mentions that Medicare pays less for a joint replacement than it did 30 years ago. From a cost standpoint we should be begging people to get knee replacements rather than treating them medically and cutting reimbursement to providers since it is a procedure, because these patients work longer, are more productive and pay more taxes so we can spend more money on less productive things such as treating diabetes, heart disease and obesity.

Ezra: But suffice to say that even though the data on whether being healthier would make health care cheaper is pretty mixed, we can still be pretty sure it's a good thing.

"Pretty sure it's a good thing" is an obvious point, and an attack on a strawman. Do you know anybody saying otherwise?

The "being healthier won't save money" argument has nothing to do with whether being healthier is desirable for it's own sake. It's simply a dose of reality that counters the panglossian view that healthier habits dramatically cut health care costs.

On the other hand, not being obese probably does make you quite a bit cheaper.

Any data on that, or is it just a meaningless "it stands to reason" type of argument? Actual numbers often play havoc with the best of arguments.

I think that the "being healthier won't save money" argument annoys people who like to indulge their authoritarian streak by inventing coercive schemes to save people from themselves. Tax soda pop? No, I'm not trying to save people from themselves, it's to save me from the (non-existent) cost externalities! Oops, numbers say otherwise. I'll just invent "reasoned arguments" - the last bastion of those afraid of data.

There are two important fallacies being addressed here.

The first is that healthy lifestyles save money. The most comprehensive data suggests that they don’t. They save money for private insurers who hand over their enrollees to Medicare at age 65, but do not save money for the system overall. Data that suggests otherwise is always gathered from care systems that handle working age patients, not from retired patients. Unfortunately, obesity and sedentary lifestyles have exactly the same impact as smoking when studied over the whole life of the patient, based on the same data sets as smoking studies.

Second, proponents of the notion of healthy lifestyles saving money often fall back on the notion of lifetime productivity as an argument that money generated by longer survivorship and better health balances out the long term health care costs. The fallacy here is that national productivity is tied to individuals. Unfortunately for fans of the Ayn Rand hypothesis almost everyone is replaceable. If Ezra has to quit blogging because of health problems there are a long line of potential replacements, some of whom may be even “better than Ezra.” In our highly technically oriented system, the same is true for almost everyone.

One additional point: there are two types of data showing our health care system to be less effective than others. The first is conventional societal population data: death rates from all causes and from specific conditions. That is in fact mostly due to cultural habits, the effects of poverty, and exclusion from health care (there was a recent study that showed that people of color and low income people closed a large part of the gap with mainstream white Americans in the first three years of being enrolled in Medicare, strongly suggesting that differences in access to health care caused by our system were a major factor in health differences for minority people and low income people.)

However, there are also studies showing that people who have been admitted to health care systems with various diagnoses ranging from trauma to diabetes to kidney disease to heart disease do worse in the US than elsewhere.

That suggests that some of our management techniques are less successful. Given the fact that evidence in the US and overseas strongly suggests that some of our common management techniques are not as effective as those routinely used elsewhere, that is not surprising. The fact is that US health care does not do as good a job of adhering to best scientific evidence as other systems, and that this accounts for a part of our underperformance.

We are doing worse not just because our people are fatter or not insured, but because in several important areas that account for large numbers of patients, large amounts of morbidity, and large numbers of deaths we are not doing as good a job as we could. The most striking evidence of this is the Dartmouth Atlas data regarding fluctuations of effectiveness in the US from region to region and from system to system, showing that differences in effectiveness of management exist not just between the US and other countries, but between systems in the US. The fact that lower effectiveness is often associated with higher costs suggests that our famous high tech medicine is not as effective as many lower cost alternatives for many common conditions.

I am a family doctor, in the ballgame for 19 years. Read what jenga wrote. Jenga is correct that preventive care does not generally save money. It costs money. On obesity :Actually, not being obese does not make your health care cheaper, or at least that assertion is unproved. See van Baal et al, PlosMed, Feb 2008, available on the web. I quote from the conclusions: "Although effective obesity prevention leads to a decrease in costs of obesity-related diseases, this decrease is offset by cost increases due to diseases unrelated to obesity in life-years gained." But you're writing an article, so you already are well familiar with the extensive medical literature on these topics, right? And you already know that preventive care costs and does not save, right? If you do not know these things, you might want to learn them before you publish your article. Failing that, please write the article for a general audience and not for people who know something about health care.

jrossi and jenga: I'm so confused now. If I'm understanding things correctly, I can start smoking again and eat everything I see at http://thisiswhyyourfat.com and not be a burden on the health care system. Maybe Jonathan Rowe is right, and cardiac surgery and knee replacements are actually better for the economy. For the record, I've read the van Baal article, and the commentary accompanying it. That commentary, written by an epidemiologist doesn't question the findings from the study but does raise some excellent criticisms about their relevance. We get into these kinds of tangles because we're using only dollars as our metric for evaluating health and lifestyle choices.

JLowe, Clearly van Baal is not the last word on this issue. I'm not even sure that he is the first word. My point was that Klein does not seem to be aware that there is in fact a considerable scientific literature on the economics of preventive care. He might want to look into it a bit if he intends to punditificate on this issue. Or not. The conventional wisdom might suffice, depending on the purpose. But if you are interested in facts ( insofar as they are known) more than rhetoric, please look at the CEA Registry online for detailed cost-effectiveness analysis of medical interventions, including prevention. You will find that some prevention is cost-effective (usually not cost saving, which is the absolute nonsense that the media often spouts), and that some treatment is cost-effective. If you have a medical or scientific background, you will be absolutely appalled by the scantiness and poor quality of much the data. But see for yourself. And the next time some damn fool tells you that preventive care will save money, punch him in the mouth for me.
That said, as a doc I'm all for appropriate preventive care, not because it saves money, but because it reduces sickness and death.
And if you want to smoke and eat fatty foods, you are committing no economic sin. Go for it!

jrossi: thanks. I'm steeling myself for doing some reading on this, because I'm fairly certain that the oncoming health care debate is going to twist this issue out of all recognition. Yes, I'm appalled with the quality and quantity of the research on this issue (I'm not a medical professional, just a lowly CIH). And, regardless of the intellectual cluster that QALY and DALY have become, I remain persuaded that cost shouldn't be our only metric for evaluating the benefits of preventive care. It's just sad that the research and public discourse aren't where they really need to be, so that we'll either end up deferring any decisions on health care or making the wrong ones. In the end, you've said something that resonates, in that preventing sickness and death has value that cannot be expressed well in dollars. For me, I avoid smoking, eat my vegetables and exercise because I look better and keep ED at bay. I'm so transparent. See you in the gym.

JLowe, I agree about the coming HC debate. Any connection to reality will be purely coincidental. But there is nonetheless some usefulness in understanding reality. And, IMHO, when thinking about whether a HC intervention is useful, the distinction between preventive and remedial care is not important. There are good and bad of each type. Consider the mother of all bad preventive measures, prostate cancer screening with PSA. It is expensive, entails risk and discomfort, and probably saves few lives. Mammography for breast CA is, regrettably, also quite a disappointment but still with doing in many patients. There is a recent excellent summary of mammography at the blog Health Beat. Contrast this with colon cancer screening with colonoscopy, which might even save money compared with no screening plus usual care. Very useful indeed. On the remedial side, contrast appendectomy for acute appendicitis (maybe fifty extra years of life for ten thousand bucks) with back surgery for herniated nucleus pulposus, which adds little to conservative care for most (not all) patients.

One important point.

I know that JRossi already knows this, but in discussing “preventative care” and costs we need to make a distinction between prevention related to lifestyles – smoking, obesity, lack of exercise – and prevention related to early and appropriate interventions in health situations. Immunizations save billions of dollars that would be spent treating the complications of formerly common illnesses (for example measles was once the most common cause of blindness in the US.) Early treatment of most infectious diseases saves billions of dollars in ER and ICU costs. Early treatment of strep infections saves billions by stopping development of heart disease and kidney failure as complications of strep.

Also, there are cost effective ways of managing chronic conditions like asthma, diabetes, and congestive failure that can save billions, usually involving more aggressive and frequent outpatient primary care management. Effective management of asthma prevents hospitalization and ER use. The British National Health Service model for diabetic care prevents costly amputations, blindness, and organ failure by monitoring patients much more closely than US models. The high intensity outpatient primary care management system for congestive failure -- pioneered in Britain but recently studied successfully by the Duluth, MN, health care system SMDC -- reduces hospital admissions and re-admissions by 80% and ER use by 75%. Poor management of congestive failure, often specifically related to lack of access to primary care providers, is the number one cause of short interval re-admission to hospitals not only for medical patients but for surgical patients as well.

In all of these things, it is the primary care providers who are at the front lines. Good primary care can and does save money. Flurries of activity regarding obesity and exercise does not.

BTW – noting the comment that joint replacement surgery has declined in cost, it is important to credit the cause: cost controls and cuts in payments by Medicare, copied by private insurance, has reduced that cost of joint replacement as well as cost for many other high tech procedures and tests.

Pat S, You make good points of course. Maybe non-medicos are confused about the terminology. When I use the term "prevention" I mean it to refer only to preventive interventions provided by the medical system. I exclude early treatment and cost-effective management of common diseases, which is of course an enormously good thing. I also exclude public health encouragement of healthy lifestyles, which is also often a good thing.

www.medtipster.com recently launched an early version of its drug price comparison Web site. Consumers type in their drug name, dosage and ZIP code, and can find prescription drugs available on discount generic programs and where they can find them in their neighborhoods. The site will eventually offer users information on scheduled immunizations, health screenings and mini-clinics in their area; recalls and warnings; an "Ask the Pharmacist" feature; and an online community in which individuals can share information.

and another thing --

JLowe is dead right in saying that we need to measure the effectiveness of health care in metrics other than money. We are not saying you should supersize your value meal. We are saying you should not expect to save money by spending more time on your treadmill. The value of good health habits is a long, higher quality life, not potential savings for Medicare.

Personally, I have a strong feeling that this argument gets so much play because opponents of health care reform want to excuse the problems in US health care by blaming the victim. They are suggesting that the reason that we have less effective health care here is that we have so many fat, alcoholic smokers, not that we exclude large numbers of people totally or partially from health care, that we spend way too much money on questionable care, and that we focus way too much on high tech intervention in health crises instead of on high quality health maintainance of the sort that JRossi and I discussed above.

Isn't it fair to say that commenters like jrossi are distorting the debate to further their own dishonest ends? I'd say so. Preventative medicine clearly saves billions of dollars in medical costs, as Pat S. pointed out. Instead of coming to terms with the increasing use of ER visits to treat ailments by the growing uninsured, the frame of the debate is shifted to tangents like obesity and smoking. Most likely a doctor like jrossi is afraid that a single payer system will emerge and he or she will make less money, ignoring the clear COST SAVINGS of having people go to a GP for antibiotics rather than an ER for a full blown infection. Too bad for jrossi that there are enough uninsured that won't be duped by this sophist trick.

Benny, I am in favor of a single payer system. And, of course, people should go to an FP (not GP in the US) or internist for antibiotics. I think we have a confusion of terms. Preventive medicine, conventionally defined, refers to interventions by the medical system, not the public health system, to prevent disease or to detect it at early stages. So defined, most preventive interventions have not been proved to save society money. Some have. Unfortunately, the data on many interventions are poor, as this is a relatively underfunded area of research. Go to Tufts University's CEA Registry if you want to get started researching this. The UK's Cochrane Collaboration is another good resource.
If you read my posts carefully, you will know that I do favor selected preventive measures because they decrease illness and death.
Perhaps you're really referring to early treatment of disease, which is clearly appropriate, but which is distinct from [preventive care. Many docs, myself included, would consider early treatment our most important job!

Benny Lava --

I don’t mean to attack you, since I think that your overall point is correct, but I have to defend JRossi from the charge that he is trying to manipulate the debate for his own personal benefit.

He is a family practitioner. Most people thinking about health care think that American family practitioners (along with pediatricians and general internists) are paid too little, and that reform needs to raise their incomes -- most likely in a budget neutral way, offset by cuts to higher paid specialists. American family practitioners actually make less right now, on average, than many British family practitioners are paid by the National Health Service. Since we are going to need a lot more primary care providers like him if we plan to get appropriate health care for all Americans, we probably need to pay them somewhat more in order to draw more people into the fields. Consequently I don't think it is right that he is trying to reframe the debate to his advantage, since reform of the type you are talking about probably IS to his advantage.

The article that is the start of this thread specifically was on the topic of whether "healthy living" could save health care dollars, which is why we all got on the topics of obesity, smoking, and exercise. JRossi is actually making the same point as I am, which is that the best evidence about this is that the answer to the question of whether those things save health care dollars is "no." Both of us agree with you that the focus on “healthy living” is a false card in the health care reform discussion.

The reason that I commented about the definition of preventative health care issues is precisely because I thought there was some danger -- some of the comments by other people suggested this -- that people would confuse the two types of prevention -- lifestyle issues vs. appropriate timely early intervention and steps like immunizations. JRossi specifically agreed with that, commenting that he thought that was understood.

JRossi and I have an ongoing relationship on several blogs that touch on health care, and on many if not most issues we are in substantial agreement – except that he thinks I am a communist ;-)

There as been actual research (gasp!) on this subject with Medicare patients. At the beginning of the study, Medicare recipients were evaluated on a standard health evaluation and categorized on a scale from "healthy" to "debilitated". The study ended after they all croaked :). What the study found was that, long-term, there was NO SIGNIFICANT DIFFERENCE in how much health care resources they used, because the healthier patients lived longer.

I'd go look up the study again (it's been a while since I read it), but I'll let you guys have that fun :). I just found it interesting reading at the time, not useful for what I was trying to find, so I didn't make a note of the URL, sorry :(.

Anyhow, as others pointed out, being healthy is its own reward, it doesn't save money long-term. But that doesn't mean you should go out and supersize your Big Mac Meal and quit exercising -- unless you *like* having a short unhealthy life, of course. Which, apparently, some do.

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Unfortunately, the data on many interventions are poor, as this is a relatively underfunded area of research. Go to Tufts University's CEA Registry if you want to get started researching this.

Early treatment of most infectious diseases saves billions of dollars in ER and ICU costs.