Public Health -- The Best Approach to Health Care Reform

The mayor and health commissioner in Louisville, Ky. have launched an intriguing program aimed at reducing health disparities in their city. What do they mean by health disparities? Infant mortality among black mothers is one-a-half times the rate of white mothers. Deaths from heart attacks and strokes among blacks is one-and-a-third times that of whites. Latino diabetes rates are significantly higher than either the white or black rates.

That's a key reason behind the fact that, when discussing the need for health care reform, so little political traction comes from pointing out that the U.S. lags so far behind other industrialized countries in key health indicators like infant mortality and longevity. Two-thirds of the population -- the white, non-poor population -- intuitively understands that it is not really their problem.

So if you want to reduce the diabetes rate in the Latino community (which would, probably, bring the U.S. rate down to rates seen in other industrialized nations), or the cardiovascular disease rate in the black community, what do you do? You could target preventive health care programs at the communities that are most at risk.

That's precisely what they're attempting to do in Louisville, where the mayor recently launched a new Center for Health Equity. The Center "will focus on the social determinants of health such as a person's job, neighborhood, income and education, as well as personal responsibility," according to an op-ed in the Louisville Courier-Journal written by Adewale Troutman, the city's health director. "It will also examine the potential for discrimination in the delivery of health care and seek solutions."

One of the Center's first projects involves the start-up of 10 to 15 track clubs for elementary and middle school children in low-income neighborhoods. The clubs will include "instruction on nutrition, attention to self esteem, and the importance of education, as well as fitness assessments." The Center also plans to establish intervention programs aimed at lowering the disproportionate rates of heart disease, diabetes and AIDS in minority communities in Louisville.

Here's my guess. Every dollar spent on the kind of interventions being tried in Louisville will be accompanied by a fivefold reduction in illness care expenses. Someone needs to do a cost-benefit analysis of their program, the same type of analysis that drug companies routinely do in order to justify the high prices charged for new drugs.

Public health approaches to health care need to become part of the health care reform debate. A city like Louisville can probably throw, at best, a few million dollars at targeted prevention efforts. But if reformers were armed with a few decent studies showing the cost-effectiveness of such programs, it could lay the basis for spending billions at the national level on programs that could substantially reduce the nation's health care bill.

That's the best way to make the national health care system affordable. Spend money to keep the American people well.