Passage of the Patient Protection and Affordable Care Act of 2010 marks an important
step toward making health care available to all Americans. However, implementation
of the legislation over the next decade faces organizational, political, and economic
challenges (1). One of the surest ways to maximize the chances for health care reform
to achieve its aims is to reduce the burden of chronic disease on the nation’s health
care system.
Chronic diseases such as heart disease, cancer, hypertension, stroke, and diabetes
now account for 80% of deaths in the United States and 75% of health care costs. In
2005, 44% of all Americans had at least 1 chronic condition and 13% had 3 or more.
By 2020, an estimated 157 million US residents will have 1 chronic condition or more
(2). Although an aging population has contributed to the increase in chronic conditions,
children and young adults face a growing prevalence of obesity, diabetes, and asthma.
Between 1996 and 2005, the number of people aged 25 to 44 years with more than 1 chronic
disease doubled (2).
Health care reform legislation promises better access to screening and early intervention
for chronic conditions for vulnerable populations. Similarly, advances in understanding
the role of the human genome in the expression of chronic conditions offers hope for
new treatments (3). Unfortunately, evidence suggests that innovations in genomic medicine
are unlikely to reduce the prevalence or costs of chronic conditions in the coming
decade (4).
To lower the incidence of chronic diseases and thus the costs they impose on our society
and health care system will require addressing the deeper causes of the increase in
recent decades. Much evidence suggests concrete action that could help to prevent
further increases in chronic diseases. We suggest 4 broad strategies.
First, the United States needs to bring its environmental and consumer protection
regulations into the 21st century. Air pollution, especially in urban and low-income
areas, contributes to illnesses and deaths from cancer and heart and respiratory diseases.
In 2002, at least 146 million people in the United States lived in areas that did
not meet at least 1 US Environmental Protection Agency air pollution standard (5).
Tobacco and alcohol use and consumption of foods high in fat, sugar, salt, and calories
contribute to a substantial proportion of chronic disease deaths, yet most of the
nation’s regulatory approaches to these products were developed in the first half
of the 20th century. New forms of marketing, product design, and retail distribution
make these old approaches insufficient to protect the population against the aggressive
promotion of these unhealthful products. In the last 3 decades, the tobacco, alcohol,
and food industries have substantially increased their efforts to oppose public health
protection against these products and to persuade consumers to use their products
(6). Developing stronger national, state, and local protections and finding new ways
to prevent these industries from externalizing their costs onto taxpayers can contribute
to reducing the behaviors that put people at risk for chronic diseases (7).
Second, the nation needs to maintain and strengthen federal, state, and local public
health infrastructure. In 2004, Frieden charged local public health officials in the
United States with being “asleep at the switch” in their response to the growing threats
from chronic disease (8). He urged stronger surveillance programs, environmental interventions,
new regulation, and more funding. In the past 2 years, however, as a result of the
economic crisis, many state and local health departments have cut funding for services,
including chronic disease control (9). This action jeopardizes prevention of chronic
diseases by increasing the flow of people with chronic illnesses into the health care
system, making it more difficult for health reform to achieve its objectives.
Third, the country needs to offer new incentives to create a built environment that
promotes health. Increased physical activity protects against several chronic conditions,
yet urban, suburban, and rural environments often make it difficult to walk, bicycle,
or use other forms of active transport. Government can help people make more healthful
choices the default choice by modifying zoning rules; developing transportation systems
that encourage active transport; and designing schools, workplaces, and communities
that promote physical activity and discourage being sedentary.
Finally, the nation’s health care system needs to modify its practices to make prevention
of chronic diseases a priority. This modification could be achieved by extending the
reach of evidence-based intervention programs; strengthening community health centers;
increasing reimbursement for services such as tobacco use cessation, nutrition, and
alcohol counseling; and providing health professionals with additional prevention
skills (10-12).
These 4 strategies offer several advantages. They rely on off-the-shelf science, reducing
the necessity of additional years of research before implementation. Each contributes
to improvements in various chronic conditions. The proposed measures can contribute
to reductions in cancer, diabetes, hypertension, and heart disease (Table), each projected
to increase in prevalence by more than 40% in the next 2 decades (10). In addition,
these strategies reduce population incidence of chronic conditions and help shrink
disparities because the targeted conditions mostly affect low-income, black, and Latino
populations.
Updating environmental and consumer protection, strengthening the public health infrastructure,
improving the built environment that influences health, and making prevention a priority
for our health care system have the potential to win broad voter and policy maker
support. Although any policy reforms that threaten the status quo will be opposed
by some special interests, these recommendations will benefit most people in the United
States, save taxpayer dollars, and help the nation to achieve its health goals. Implementing
the 4 simultaneously will help to achieve synergies that can accelerate and magnify
their effect. By providing the leadership needed to realize these changes, health
professionals can increase the likelihood that health care reform will succeed and
that the nation’s health will improve.