New legislation dropped in the final days of a Congressional session obviously isn't going anywhere. But it does signal what that legislator thinks is important and plans to push next year. And when that legislator is Sen. Hillary Rodham Clinton and the bill involves health care, it merits close attention.

On October 1st, the junior senator from New York introduced a bill that would channel existing payments by both public and private insurers for preventive health services into a new Wellness Trust, which would then pay for all preventive services in this society. You can think of it as Medicare Part "P," except that it isn't just for the nation's elderly.

The new Wellness Trust would be run by 7-member board appointed by the president and approved by the Senate. Under S. 3674, the Wellness Trust in its first year of operation would commission and then issue reports on the best way to supplement the existing health care workforce with certified "prevention health workers"; establish new reimbursement systems that would "align incentives" with health promotion and disease prevention goals; and analyze current expenditures on prevention, which the bill estimates at 1 to 3 percent of health care costs or $20 billion to $60 billion.

A year in, with those reports in hand, the trustees would then begin collecting all payments made by Medicare, Medicaid and insurance companies for existing prevention services. The agency would then designate its own "prevention priorities." These would include community-based strategies like tobacco and alcohol counseling or diabetes prevention education, as well as the usual clinical services like the colonoscopies, mammograms and vaccinations that most people associate with preventive care.

With these priorities and money in hand, the Wellness Trust trustees would enter into contracts with certified prevention providers to deliver the services deemed the highest priorites "without regard to the insurance status of such individuals."

The legislation tracks closely to a report that Jeanne Lambrew, now at the University of Texas, wrote for the Hamilton Project at the Brookings Institution, which was created by former Secretary Treasury and Citicorp board member Robert Rubin to serve as a policy think tank for the next Democratic administration.

There's an outside chance the proposal will find a receptive ear in the next administration, whoever is elected. Prevention is included in the health care planks of both candidates. Yet neither has stressed the issue on the campaign trial.

That's not surprising. The conventional wisdom that recently emerged from the health care policy world is that strategies for preventing chronic disease -- which is responsible for 75 percent of all health care expenditures -- don't pay. They only add another layer of cost to the system and won't lower other health care expenditures for many years, if at all.

In my view, that's hogwash. Some prevention interventions lower costs, and some cost far more than they are worth -- just like health care interventions. For a critique of the new conventional wisdom on prevention, intially laid out in a New England Journal of Medicine article, see this GoozNews post.

The Clinton bill pushes back even harder. By centralizing all the money spent on prevention in a single agency, the government could deploy those limited resources in the most cost-effective manner. Moreover, it could target the populations most in need of prevention information, advice and services -- low and moderate-income people who are the most at risk of chronic disease because of poor education, low income, high stress, poor diet, and the lack of exercise that lead to unidentified or untreated pre-disease conditions like hypertension, high blood sugar, smoking, and alcohol abuse.

Right now, the prevention priorities of the nation are driven by who is best insured and a member of what University of Minnesota bioethicist Carl Elliott has called the worried well: educated consumers who know how to demand every high-end preventive service that health care providers can dream up. Have you been told yet that you ought to get a heart scan just to make sure there aren't any blockages forming in your arteries? I have, and I didn't appreciate the pressure to spend money out of my own pocket to get something I probably don't need.

Meanwhile, hundreds of people within a few miles of my house go without screening for hypertension, even though two-thirds of the people with high blood pressure in this country have neither been diagnosed nor treated for this condition, which leads inexorably to heart disease.

Opposition to the creation of a Wellness Trust will be fierce. A lot of the services that generate a lot of cash for a lot of doctors and clinics -- like prostate cancer screening for old men -- do not make it onto the U.S. Preventive Services Task Force recommended list. Presumably they wouldn't make it through a Wellness Trust screen. It would be the right call. Millions of men get those tests and are treated for prostate cancer when they would be better off simply watching and waiting.

But the physician, drug and testing industry would lose those customers. It's hard not to conclude that given the broad range of prevention services of dubious utility currently being offered, the opposition to a more rational use of these limited resources would be fierce.

There is an alternative funding mechanism to the one laid out in the Clinton bill. Instead of a direct assault on useless services, high priority services, both clinical and community-based, that are not provided by the existing health care system could be funded through dedicated taxes earmarked for the new Wellness Trust. While this would be a new layer of spending, it wouldn't come from traditional health care payers like Medicare, Medicaid or the private insurers, who could continue to work on limiting their expenses for services of limited value.

What are the logical new taxes for a Wellness Trust? How about raising the national cigarette tax? In the parlance of the economics texts, this would merely be internalizing costs to a product that is causing grave damage whose costs are currently being absorbed by the health care system. And how about alcohol taxes? The national levy on alcohol hasn't been raised since 1991 and has fallen as a percent of total sales by more than 40 percent, despite the estimated $100 billion a year in lost productivity, absenteeism and social problems caused by its abuse. We could even begin talking about a national soda pop tax. Doesn't it make sense to fund programs aimed at preventing childhood obesity, which leads to lifelong obesity, with a tax on a product whose over-promotion and ubiquity contributes to this epidemic?

I can already hear the critics. Take on the tobacco, alcohol and soda producers simultaneously to fund prevention? You've got to be kidding. These are some of the most powerful and well-heeled lobbyists in Washington.

But the proposed funding mechanism in Sen. Clinton's bill is even more sweeping. The medical specialties that deliver high-cost/low-value preventive services will brand the Wellness Trust as an attack on needed health care benefits and a centralization of health care services. These are precisely the messages that average Americans don't want to hear when it comes to health.

When it comes to providing the much-needed community and clinic-based preventive services that have been so woefully underfunded in the past, it's a question of which lobbies do the advocates want to go up against. It seems to me it will be a lot harder to go after those providing high-end and often wasteful clinical preventive services than it will be to tax industries whose products are contributing to the problem in the first place.