The Value of Prevention… and the Question of Responsibility

One of the functions that government performs best, in the sense that it is a function that can seldom be performed on a societal-wide basis by any other entity, is the one that citizens often have the least understanding of and/or the least willingness to support, with one or two notable exceptions.  That function?  To keep bad things from happening… or from getting worse once they happen.

Examples of such are police protection, trash collection, clean water, and effective sewer systems.  All of these are well-accepted government services with a large element of prevention embodied in their function. Other preventive government functions are not so well understood or accepted.

At one time, environment standards were fought tooth and nail by industry.  Now various industries fight new or tighter emission standards, but those standards are designed for one function – to prevent the emission of pollutants that harm people, and without those standards we had rivers where nothing could live, and some that even caught fire, air that caused hundreds of thousands of deaths, water supplies containing virulent carcinogenic chemicals… and so forth.

More than a few people have complained about the massive federal government spending on counter-terrorism, now estimated at $150 billion annually, just in the United States.  In 2011, the most-recent year of the Global Terrorism Index, there were 4,564 terrorist incidents that led to 7,473 deaths.  In the United States, there were actually more terrorist attacks in the 1970s than in any decade since – although the 9/11 attack was the deadliest in U.S. history – but since 9/11 the overall numbers of successful terrorist attacks have continued to decline, almost certainly due to increased security measures and, some would say, a certain restriction on personal freedoms.  But consider this.  Since 9/11, only 37 people have died from terrorist attacks and assaults in the United States.  While this apparatus hasn’t prevented those deaths, how many others has it prevented?  How can anyone tell? 

Vaccination is another area of prevention, although some parents still don’t understand vaccination or the need for it, but that’s an area where some quantification does exist. For example, even today, according to the World Health Organization over 100,000 people die every year from measles, yet there have only been few hundred cases annually in the United States over the past several decades, all of which occurred in unvaccinated individuals.  Before the development of the vaccine, there were often close to a million cases a year in the U.S., and as many as 7,000 deaths.  More recently, nearly a million people died world-wide annually from measles in years before 1999, when more wide-spread use of vaccines became available.  Yet in recent years, there have been parents who insist that the vaccine is more deadly than the disease, despite long-standing figures that shown mortality from measles ranges from one death in a thousand cases in healthy and well-nourished individuals to as high as 300 in a thousand (30%) for weakened or malnourished individuals.  By comparison, severe side effects from the vaccine are less than one in a million, and fatal side effects so low that they cannot be quantified.  For all that, some parents still insist that their child is safer without being vaccinated.

Another area of successful prevention is that of automobile safety. The all-time high in automobile deaths was almost 55,000 in 1972, when the population was a third lower than it is now, but by 2011, that had dropped to 32,367, the lowest total in 60 years. Since 1960, the number of vehicles on the road has tripled and population has increased by 50%, yet automobile fatalities per 100,000 people have been halved.  The cost?  Adjusted for inflation, the cost of an average new car is roughly 140% higher than that of a 1973 new car, when the first significant mandated federal safety standards were imposed.   Assuming that no such standards were implemented, a conservative estimate suggests that we would have seen roughly a half-million more deaths than actually occurred, and most likely at least as many additional injuries. The problem with trying to quantify the costs is that it’s impossible to determine how much of the reduction in fatalities comes from improved design and how much from safety features and other factors, such as seatbelt laws.  That preventive measures have had a huge impact isn’t even in doubt, but we still have thousands of deaths a year because drivers don’t wear seatbelts, either because they don’t think it can happen to them or because they’re exercising a perverse form of civil disobedience.

Similar questions arise in healthcare.  Some critics have pointed out that the largest cause of death in the United States is heart disease, followed by cancer, strokes, and hospital infections.  Yet the most effective form of prevention is a healthy life-style, particularly avoiding obesity, tobacco use, and excessive consumption of alcohol while engaging in regular exercise. For all that knowledge, over forty million people still smoke, and over 30% of the population is obese, while excessive consumption of alcohol is a problem faced by at least 15% of the population. The cost of a single day’s treatment in a hospital for someone with a suspected heart attack can easily exceed $5,000 and the course of treatment for an actual heart attack can run many times that, and we – or our insurance carriers, or both – as a nation spend an estimated $500 billion in healthcare expenditures that could be greatly reduced if more people made, or were able to make, a greater effort toward a healthier lifestyle.

Some kinds of prevention, such as requiring vaccinations, drastically reduce death rates and costs for a tiny fraction of just what burial costs would be.  Others, such as automobile safety features, are still obviously cost-effective, but both are effective because the prevention is not only required, but it can be largely implemented.  Basic environmental standards are clearly cost-effective, but regulators and attorneys continue to argue about the need for tighter or additional environmental regulations and whether they improve health and the environment compared to the cost to those who must comply.  Nonetheless, some kinds of prevention can only be accomplished by government.  No individual, for practical purposes, can prevent air and water pollution or require automotive safety standards, or clean drinking water and safe sewage disposal.

In healthcare, the matter is even stickier.  Healthcare providers – or the government – cannot not only not require people to adopt a healthy lifestyle, but are greatly limited in requiring people who maintain unhealthy lifestyles to pay their full share of the additional healthcare costs required by such individuals. In fact, the current direction of U.S. healthcare is away from requiring individual responsibility, even as a host of government regulations require it in other areas.

Prevention — who pays for it?  Who should?  How much? And to what degree should people be made personally responsible for their own failures to prevent the preventable?

3 thoughts on “The Value of Prevention… and the Question of Responsibility”

  1. Kathryn says:

    A brief comment for now:

    I’m in the UK, which means I have access to a healthcare system I don’t have to pay directly for. I can go to my doctor without having to worry about paying for any treatment, because the majority of treatments are free (on the basis that you access them for free, etc., but you pay a percentage of your earnings as ‘National Insurance’ once you earn so much a month). This perhaps puts the responsibility on the NHS to keep costs down, so they promote healthy living schemes, give free advice on how to stop smoking and so on.

    It’s not like the US system where the responsibility is more on the ‘consumer’ (as it were) as they would be footing the bill for any treatment. And given the cost of US healthcare and/or the issues with getting health insurance, it’s very hard for a lot of US citizens (particularly the poorer ones) to get the help and support they need.

  2. Therman says:

    Very good post. Personally, I would have no problem if insurers were allowed to charge persons engaging in unhealthy lifestyles a premium on their policies. I myself, as I’ve gotten older have put on a few extra pounds. If I knew my insurance was going increase 20% or more because of that extra 15-20 pounds, I would probably take serious steps to bring my weight back down. And if I decided not to, then I would be choosing to pay the premium to maintain my lifestyle. The difficulty would lie in the honesty of the customer or proving their deception.

    Some of the additional cost due to unhealthy lifestyle is currently being captured in the sin taxes (alchohol and tobacco primarily) but I have no idea if these tax revenues actually are applied to public health funds or not. I also don’t know if they would be sufficient to offset additional charges made on Medicare and Medicaid but I’m fairly sure they don’t compensate the insured who maintain a healthy lifestyle who pay higher premiums due to those who do not. Interesting question though.

    However, when you are talking about prevention in general, there is the follow up question, ‘How much is enough?’. I think in many areas we have passed the point of diminishing returns.

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