Written Statement Steven H. Woolf, M.D., M.P.H. Professor of Family Medicine, Epidemiology and Community Health Virginia Commonwealth University before the U.S. Senate Special Committee on Aging The inherent logic behind prevention is obvious. The major diseases that claim the lives of Americans and that account so greatly for the rising costs of health care are caused largely by health habits, such as smoking, physical inactivity, and poor diet. Fully 35% of deaths in the United States are caused by three behaviors: tobacco use, poor diet, and physical inactivity. The major diseases of our time can often be detected early and either prevented or made less severe. Our society spends far too much on treating the end stages of disease and far too little on helping the public avoid getting sick in the first place. As the Governor of Arkansas, Mike Huckabee, has said, rather than building a fence at the top of the cliff, our health care systems keeps sending one ambulance after another to the bottom. Paying for prevention is far more effective than paying for chronic disease care. Whereas treatments for cardiovascular disease can save 4,000-10,000 lives per year, helping Americans to stop smoking would prevent more than 400,000 deaths per year. This is true for adults and children and it is true for seniors, who are not too old to benefit from prevention. Seniors live longer and live healthier if they abandon unhealthy behaviors, obtain recommended vaccines, and receive certain screening tests to catch diseases in their early stages. For example, lifelong smokers who stop smoking at age 50 live an average of 6 years longer than those who continue smoking beyond that age. Prevention can improve function, postpone chronic disease and disability, and avoid premature death. Recent evidence even suggests that physical activity may delay the onset of Alzheimer's disease. Prevention is an obvious answer to the escalating costs of healthcare. Promoting prevention among seniors should be a major public policy priority. This was always true but is especially pertinent now, a time when Americans are growing older in greater numbers. The aging of the baby boom population, combined with advances in medical care, is carving out a future in which a larger number of seniors will suffer the health complications associated with chronic diseases, such as heart failure, diabetes, and cancer. Promoting prevention is intelligent planning for the future. Primary versus secondary prevention Two forms of prevention deserve emphasis among seniors: primary prevention and secondary prevention. Primary prevention refers to actions by asymptomatic persons to prevent disease from occurring in the first place. Examples include good health habits, such as regular physical activity, eating wisely, and stopping cigarette smoking. As already noted, one out of three deaths in the United States is caused by these habits. The rising rate of obesity further threatens to cut short the life expectancy of Americans. Another example of primary prevention is immunizations, such as influenza (flu) vaccine and pneumococcal vaccine, which prevent seniors from getting infections such as pneumonia, a leading causes of death. Secondary prevention refers to screening tests and other strategies to detect diseases in their early stages. Examples include mammograms, screening for colon cancer, and measurement of bone density to detect osteoporosis. Some of these tests can reduce death rates from diseases by 20-30%. Although screening tests can be beneficial in reducing morbidity and mortality from diseases, the benefits of early detection are limited because, by definition, the disease process is already underway. Clinical preventive services refer to efforts at primary and second prevention that are undertaken by doctors and other healthcare providers in clinical settings, such as doctors' offices. Efforts by Congress to expand coverage of clinical preventive services under Medicare have gone a long way to improving seniors' access to immunizations and screening tests. Prevention is an undertaking that extends beyond the clinical setting, however. To be effective communities must provide a web of integrated services to help citizens sustain healthy behaviors. Ideally, a person who chooses to become physically active should find a community working together to support the effort. The individual's physician might recommend exercise, but local media and advertising can reinforce the message, employers can offer incentives, and the "built environment" (e.g., neighborhood walkways) can be redesigned to foster outdoor activity. A diverse collaboration is required to give citizens a seamless support system for healthy diet, physical activity, smoking cessation, and alcohol moderation. It includes not only local health systems but also school boards, park authorities, worksites, churches, bars, restaurants, theaters, sports centers, grocers and other retail outlets, voluntary organizations, senior centers, news media, advertisers, urban planners, and the leaders who set direction for these sectors. Gaps in prevention among seniors Both primary and secondary prevention among today's seniors falls short of the ideal, claiming lives in the process. Unhealthy behaviors are prevalent among older adults. Primary prevention, among the most effective strategies to reduce the burden of chronic disease, is practiced by a minority of seniors. For every 100 adults age 65 and older, 25 are obese, 25 engage in no leisure-time physical activity, and 10 smoke cigarettes. Fully 4.5 million seniors smoke cigarettes. Gaps in immunizations are substantial. One out of three seniors has never received pneumococcal vaccine, which can significantly reduce the incidence of pneumonia and pneumococcal infections and is therefore recommended for all adults age 65 and older. In 2003, 30% of older adults had not received a flu shot in the prior year. Efforts by Congress to expand coverage for preventive services under Medicare have gone a long way to remove a major barrier that has limited the ability of seniors to receive recommended immunizations and screening tests. Many of the preventive services recommended for seniors by the U.S. Preventive Services Task Force are now covered under Medicare. The Medicare Modernization Act (MMA) of 2003 introduced the "Welcome to Medicare" visit for new beneficiaries and expanded coverage for cardiovascular and diabetes screening. But coverage alone does not ensure the delivery of clinical preventive services. The General Accountability Office reports that only 10% of Medicare beneficiaries have been screened for cervical, breast, and colon cancer and also immunized against influenza and pneumonia. Insurance is not the only barrier to receiving clinical preventive services. Health disparities among seniors Some seniors are more apt than others to enjoy good health habits and obtain clinical preventive services. For example, a recent study by Dr. Clark Denny and colleagues, in the May issue of the American Journal of Public Health, reported that Native Americans age 55 and older are 1.5-2 times more likely than whites of the same age to be obese, to be inactive, and to smoke cigarettes. Similar disparities in unfavorable risk factors exist among African American, Hispanic, and other seniors in minority groups. According to a recent study by Dr Paul Hebert and colleagues in the April issue of Health Services Research, 67% of white beneficiaries have received a recent flu shot but only 53% of Hispanic and 43% of African American beneficiaries had been vaccinated. Other investigators reported that, whereas pneumococcal vaccine is received by 66% of white Medicare beneficiaries above age 65, only 51% of African Americans in the same age group have been vaccinated. In 2001, 30% of Medicare beneficiaries had received a home stool test for colon cancer, but the same was true of only 20% of Medicare beneficiaries without a high school education. Death rates are higher and life expectancy lower among seniors who are members of racial and ethnic minority groups or who are of low socioeconomic status. Americans age 65-74 are almost 50% more likely to die in the next year if they are African American than if they are white. Medical advances, the research enterprise in which our society invests billions of dollars per year, do save lives. But more lives could be saved by solving the causes of these disparities. In a study published by our team at Virginia Commonwealth University in the December 2004 issue of the American Journal of Public Health, we showed that, for every life saved by medical advances, five would be saved by correcting the disparity in death rates between African Americans and whites. Compared to gene mapping and stem cell research, fixing the causes of disparities is less glamorous and less likely to make the evening news, but it is far more likely to save lives. Congress should support research to understand and correct disparities in the health status and healthcare of disadvantaged persons and minorities. Policy Solutions Healthy aging with its tremendous promise to save lives and reduce the costs of healthcare cannot become a reality for America's seniors unless our leaders confront the underlying conditions that account for gaps and disparities in primary and secondary prevention. Confronting—and fixing these conditions will come at some cost, both economic and political, but the resulting savings in lives and dollars are enormous. What follows are examples of potential policy solutions, but Congress should assemble a more comprehensive list by collecting the best minds and best ideas on this topic. Constraints on today's resources are recognized, but the toll in lives and in escalating healthcare costs compels the nation's leaders to not invest timidly in healthy aging. Congress should see the wisdom of drawing off its enormous investments in disease treatments to spend more on the prevention of disease. Following are examples of specific policy approaches that might be taken: Public education The first step in shifting the dynamics toward healthy aging is to convince decisionmakers, including seniors, about the importance of prevention. Studies have shown consistently that mass communication is an effective strategy to promote prevention and change health behaviors. The visibility of Congress gives it tremendous leverage to convey the message that prevention matters. An initiative with press events, legislative action, and the resulting media attention, led by Senators and Representatives with a commitment to prevention, could urge American seniors to pursue good health habits and obtain recommended vaccines and screening tests. Wise use of social marketing techniques and experts could markedly amplify the effectiveness of a public education campaign. The campaign should be designed to employ the optimal media channels to reach seniors and the best ways to package a persuasive message, especially for seniors who face language or literacy barriers. On a similar note, the Centers for Medicare and Medicaid Services (CMS) could do more to promote prevention among seniors. In the past year CMS has taken several important steps to make beneficiaries aware of the new preventive benefits authorized under the MMA. In addition to press events, many of them hosted by Dr. McClellan and conducted jointly with leaders of major health organizations, new publications and website resources for beneficiaries have been disseminated to describe the new preventive benefits. But a closer look reveals much more that could be done to educate seniors about the Medicare The Official US. Government Site for Feople wall: Medicare Search Medicare.gov My Medicare.gov Medicare Bling Medicare Appeals Long-Term Care▸ Plan Chalces > Stay Healthy▸ Address Change Replacement Card Medicaid Enrollment Provider Information Glassery Privacy Practices Stay Healthy Welcome to the Staying Healthy section of our website. The purpose of this section is to provide visitors with information about preventive services that are available to people with Medicare. Prevention is the first step in staying healthy. Important Health News Preventive Services Medicare pays for many preventive services. The preventive services include the following (please select the links below to view additional information): The page does a good job of listing the full complement of preventive services covered by Medicare, a credit to the good work of Congress, but says very little about how to "stay healthy." The page is silent about primary prevention. Beneficiaries need information and encouragement to live healthy lifestyles, with messages that remind them about the importance of stopping smoking, staying active, eating well, and controlling their weight. Nor does the page explain the meaning of a “preventive service” or its importance to seniors. To be motivated to take full advantage of the preventive services covered under Medicare, beneficiaries first need to know why prevention matters. They need to understand why preventive services from their clinician are important, which ones are |