Still looking for a free lunch in health care

True or false?

1. It's less expensive to pay for prevention than to pay for treatment
2. The US spends less on prevention than other rich countries
3. Emergency rooms are overcrowded because that's where uninsured patients go for care
4. Universal coverage will pay for itself by shifting the uninsured from the emergency room to primary care physician offices

You wouldn't know it from the candidates or even based on common sense, but all of these statements are false.As the Washington Post reveals (In the Balance, Some Candidates Disagree, but Studies Show It's Often Cheaper To Let People Get Sick), it's been shown for 20 years that prevention strategies usually don't pay for themselves. That doesn't mean health insurance shouldn't pay for preventive services. Sometimes prevention works, and that's great for the individual, even if the cost is higher. The article quotes Joshua T. Cohen of the Center for the Evaluation of Value and Risk in Health (CEVR), who pours cold water on the idea of prevention as a panacea for cost. I met Josh and the center's director, Peter Neumann, last week. They may not always tell people what they want to hear --but hey, the truth hurts sometimes.All of the major presidential candidates assert that prevention is going to help reduce health costs, and either imply or state outright that we don't spend enough in that area. But a the US already spends more per capita on prevention than any other country.Certainly there are examples of uninsured patients who use the emergency room because lack of coverage means they don't go to primary care physicians. However, an Annals of Emergency Medicine study shows that affluent patients are driving a high and rising share of emergency room visits. As lead author Ellen Weber says:

If the rise in visits is inappropriately attributed to the uninsured, programs to reduce emergency department crowding may be misdirected and fail to address its real underlying causes.

For similar reasons, universal coverage is likely to drive up overall costs as newly insured patients go to office-based physicians more and also use the emergency room at a higher rate as I've described before.The health care cost problem is not hopeless. In particular I'm hopeful that consumerism, quality and patient safety initiatives will bear fruit. Embracing prevention and improving access are good ideas, we just shouldn't expect them to resolve the cost crisis.