Much of the health care reform debate has focused on a couple of controversial provisions: what role, if any, for a public plan; abortion and federal funding in the exchanges; can illegal immigrants buy insurance with their own money; and how to pay for the coverage expansions. With these more controversial elements assuming center stage, it has been easy to lose focus of what the reforms were trying to accomplish. The first goal was to move along the path toward universal coverage -- both the House and Senate bills accomplished this.  The second was to improve the quality of care provided -- and indeed, several provisions in the legislation would achieve this end as well. A third goal was to slow the growth in health care spending. Certainly, the proposals would do so for Medicare and Medicaid; many of the provisions would spill over and impact the growth in private insurance as well, such as lower administrative costs, improvements in hospital productivity, and (though controversial) providing incentives for workers to select less generous benefits.

If we are really going to slow the growth in spending, we need to go to the key drivers. First, about a third of the rise in spending over the past couple of decades is linked to the doubling of obesity and with it the incidence of chronic illness. Second, virtually all of what we spend on health care is linked to chronically ill patients. Addressing these issues will require a focus and dedication to developing new, widely available, approaches for preventing disease and more effectively treating chronically ill patients.

Several aspects of the current proposals would move us in the right direction. The sections on wellness, prevention and, to a lesser extent, care management represent major innovative change outlined in the Senate and House bills.  For example, an important new national planning capacity is assisted by the creation of a National Prevention, Health Promotion and Public Health Council, which would facilitate federal coordination of these issues (sect 4001). There are several (and often overlapping) proposals to bolster community based primary prevention and wellness programs. Examples of these are outlined in sections 4201 and 4202 that would provide funding to communities to develop evidence based approaches for reducing the prevalence of chronic disease. These new programs could and should be coordinated with existing stimulus funds targeting similar goals and aims. My preference would be to accelerate the availability of community-based programs based on the diabetes prevention program (DPP) model (or other similar evidenced based models) that has been shown to REDUCE costs within a short period of time. Such programs should be universally available within the next three years.

The proposals also envisions a prevention and wellness trust fund (Section 4002 in the Senate and 2301 in the House bill) to fund prevention, wellness and public health activities. This modest funding would start the process of rebalancing the dramatic tilt in health care spending toward treatment rather than all forms of prevention. It would seem essential to keep this common sense proposal in the final version, hopefully at the higher House level of funding.

Several key changes are proposed in the Medicare program as well. This includes new benefits (sect 4103) that provide for a personalized care plan and health risk assessment for seniors (though as I discuss below it does not fund care coordination to assist patients in following their new care plans!). In addition, cost sharing for clinical preventive services (sect 4104 and 4106 for Medicaid) covered by Medicare would be eliminated. Virtual elimination of the part D donut hole will also improve compliance and persistency in prescription fills and refills.

While the Congressional bills make important changes in both primary and secondary prevention initiatives, the proposals are less aggressive and visionary with respect to tertiary (care management) prevention, particularly in traditional Medicare. Despite the fact that virtually all the spending in Medicare is linked to chronically ill patients, Medicare -- unlike other payers -- does not fund or encourage care coordination in preventing and treating patients. One notable exception in the current Senate bill is the inclusion of section 3502  that would establish community health teams designed to integrate primary prevention and treatment. These teams would include nurses, nurse practitioners, mental health and social workers, community-based public health nurses, nutritionists, diabetes educators among other primary care providers. The teams would work with provider practices, clinics and community health centers to provide prevention and care management services starting with Medicare and Medicaid. The functions provided by the teams are designed to improve quality and reduce costs, and a substantial body of research shows that appropriately designed the teams would achieve these goals. One function would be to work with Medicare patients to assist them in understanding and following the car plan newly funded under the reform proposals.

While the community health team and medical home approaches makes common sense, they are not adequately funded in the proposals. Like the community-based prevention programs, these teams could be scaled and replicated in a relatively short period of time. Both approaches would transform how we prevent and manage chronic illness and would represent real change. It will be important for teams as outlined in section 3502 to be established over the next couple of years to address the rising rates of preventable chronic disease among Americans of all ages. The current health care reform proposals represent a good start, but its only that—a start.

These less well-advertised, common sense reform proposals have the opportunity to change how we prevent and treat chronic illness. We need to be aggressive in implementing evidence-based models, and provide appropriate start up funds to invest in them. We used this strategy to invest in health information technology in the stimulus bill. Prevention needs the same investment and sense of urgency.