24 April 2019

By Gary A. Puckrein, PhD

In the last installment of this blog, I discussed the Founding Fathers’ understanding that governments are constituted primarily to preserve life, liberty, and the pursuit of happiness. In this post I call attention to a 2009 letter written by Douglas W. Elmendorf, director of the Congressional Budget Office, that illustrates how violations of the prime directive to preserve life have been normalized in current public policy. 

Director Elmendorf’s letter responded to a question posed by Nathan Deal, the ranking member of the US House Committee on Energy and Commerce’s Subcommittee on Health, during hearings on the Affordable Care Act, when the idea was put forward that by expanding preventive services in Medicare, costly health events could be avoided and the resulting savings could be used to help underwrite health-care insurance for the uninsured. Congressman Deal asked Director Elmendorf whether the Congressional Budget Office’s methods of scoring proposals to expand governmental support for preventive medical care and wellness services reflected potential reductions in federal costs from improvements in health that might result from expanded support for those activities. 

Director Elmendorf answered, “Although different types of preventive care have different effects on spending, the evidence suggests that for most preventive services, expanded utilization leads to higher, not lower, medical spending overall.” He reported that “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.” Because doctors do not know beforehand which patients will develop costly illnesses, provision of preventive care must include patients who will not develop those illnesses. 

The letter referenced a review of preventive-service recommendations by the American Diabetes Association, the American Heart Association, and the American Cancer Society: “The researchers found that those steps would substantially reduce the projected number of heart attacks and strokes that occurred but would also increase total spending on medical care because the ultimate savings would offset only about 10 percent of the costs of the preventive services, on average.” 

The letter noted that preventive services may also increase longevity—a desirable effect that would ultimately increase outlays for Social Security and Medicare. A longer lifespan allows for more time to incur health-care expenses associated with age. 

Conserving life is an expensive proposition, particularly if contrasted to the alternative. It is far cheaper for government not to intervene, not to offer preventive or wellness services, and to allow nature to dispatch each of us promptly, but that would be an utter violation of its prime directive. The value of preventive services should not be determined by cost savings; we need to understand that we are making a societal investment that has a broader purpose. Each life conserved each day brings us closer to controlling health outcomes and mastering the means to conserve life. When we are fully woke, we will have a better understanding of our mission and our place in its history. We are in the process of learning and empowering ourselves to build sustainable healthy communities that value life expectancy more than the gross domestic product or the savings to be reaped from failing to provide preventive or wellness services. Our common purpose is to conserve life, and, as declared in 1776, “to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed.” We must align our health policies with our social contract.

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