Dr. Neal Halfon is the director of the UCLA Center for Healthier Children, Families and Communities. He is also a professor at the UCLA Departments of Pediatrics, Health Sciences, and Policy Studies.
Any prescription for treating, if not curing, looming budget deficits and making America fiscally solvent will include a large dose of healthcare cost control. Competing plans for reigning in Medicare and Medicaid costs will be front page material for the next year as Democrats and Republicans spar over the best way to decrease the impact of these entitlement programs on deficit spending and long-term fiscal liabilities. Many Republicans favor moving Medicare to a premium support program which would provide seniors payment for a portion of commercially available healthcare plans. Democrats would prefer to tinker with Medicare payroll tax levels, age of eligibility, and other ways of controlling costs.
Unfortunately, neither strategy is likely to deal with the underlying causes of cost increases. Both strategies are just different ways of kicking the proverbial can down the road by proposing short-term economic fixes to what are long-term secular changes in cost drivers.
The major driver of Medicare cost increase is expenditures on chronic disease, accounting for nearly two-thirds of the increase in recent years. While more and more individuals are living into their 70s, 80s, and 90s, this burgeoning population is significantly burdened with costly chronic conditions. While the prevalence of chronic health problems from diabetes to depression is increasing, very little is being done to address the origins and development of these largely preventable chronic diseases.
Individual and population health follow a trajectory. More and more research is clearly showing that early health influences are critical, and that lifelong health trajectories are initiated and programmed in utero, and formulated during the early years—right through adolescence. While the impact of poverty and other social adversity on the health trajectories of young children is well documented, it is not only the poorest children that are at greatest risk for lifelong health problems. Many low income and middle class families are also squeezed by lower wages, higher costs of living, and a lack of adequate education and support services that their children need to arrive at school healthy and ready to learn. Several decades of research shows that children who are deprived of the developmental scaffolding that guarantees a healthy trajectory are more likely to experience school failure, teen pregnancy, criminality, and substance abuse during the second decade; obesity, elevated blood pressure, and depression by the third and fourth decade; coronary artery disease, diabetes, and renal disease by the fifth and sixth decades; and premature aging and memory loss in old age.
If we are truly going to deal with the drivers of rapidly increasing healthcare costs we need to decrease the number of people with expensive chronic health conditions. The United States has gotten away with this pay-for-failure strategy for many years because its economy was growing steadily and funds were available for rescue programs. So, if 15-30 percent of kids did not reach full potential, it didn't really matter. There were other workers to take their place and a safety net system to pay for their health and social dependency needs. This kind of policy stance condemned many children to never reaching their biological, health, and educational potential. The long-term consequence of continuing our current policies is that the United States will have higher dependency rates and much higher healthcare costs than is befitting of our stature as a wealthy Western democracy. But as we leave the industrial era and enter a much more competitive global information-based economy, the United States needs more of its children to reach and complete college. We also must bring down the healthcare and dependency costs caused by a growing population of adults with chronic physical and mental health conditions. Achieving both of those goals requires the same solution: optimizing health and development pathways in the early years.
The United States needs to figure out how to shift efforts and resources and focus upstream. We need to recognize the folly of trying to bend the healthcare cost curve by primarily searching for efficiencies at the end of life. The more money spent at the end of the lifespan on high cost treatments for preventable diseases means less money to spend upstream on improving early childhood health and development and education. If we are going to really shift the cost curve into a lower trajectory, we need to shift the health curve in to a higher trajectory. The most leveraged and cost effective way to do that is to focus on the time in life when health trajectories are being formed, developed, and launched. The nations we compete with have already done this or are moving in this direction. It is time we look around, review the science, and move into the 21st century.
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