For all their disagreement about how to fix the U.S. healthcare system, the current crop of presidential candidates shares a common belief about the high value of prevention. This is sensible: Preventive medicine can avert illnesses and all the expense of treating them before they start. And for people whose faulty genes trigger disease, they can be monitored, with early intervention reducing the usual rate of complications. By focusing on wellness rather than sickness, prevention is supposed to not just make us healthier, but also save money.

 

It seems odd, then, that while everyone acknowledges the advantages of wellness, we have made so little progress in bringing preventive medicine into our healthcare system. Just how little value our system actually places on keeping people healthy, though, is obvious if we follow the dollar. Public and private insurers pay for hospitals, surgeries, and drugs; doctors are generally compensated for providing tests and procedures—the more they provide, the more they make. This creates clear financial incentives to produce lots of tests and procedures, independent of what may be best for the patient.

 

In practice, of course, professional medical care is just one factor affecting wellness. For each of us, genetics and physical and social environments, along with the insight and personal discipline we bring to the management of our health, all play important roles.

 

Today, much interest in prevention is related to collecting personal genetic data and making that information available for prospective health management. This is expensive, though it’s getting cheaper by the month. What to do with this new wealth of genetic information—how to connect it to the right diagnostics and therapeutics—presents formidable, but ultimately manageable, challenges to patients and physicians alike.

 

More challenging is how to reorient today’s payment system, which, when it comes to preventing illness, is seriously misaligned. A doctor who keeps her patients from developing back pain with a program of diet and stretching is lucky to receive $100 per office visit, while the typical hospital bill for lumbar fusion surgery, according to a recent New York Times story, exceeds $50,000. Small wonder that in the United States the percentage of primary care physicians is dwindling as medical students increasingly decide to become specialists who perform lucrative procedures.

 

There’s no easy solution. Unlike other industrialized democracies, the U.S. has no lifecycle insurance. Around the world, from Japan to Norway, citizens typically receive government-sponsored medical coverage from cradle to grave. These government payers thus have a financial incentive to invest in health measures that pay off throughout a person’s lifetime.

 

In contrast, private insurance companies in the U.S. generally enroll people on an annual basis. And when employees change jobs, they usually change insurers. It’s easy to see why Blue Cross would be reluctant to invest in the long-term health of a customer who will probably move in three years to Kaiser.

 

Still, the biggest obstacle to effective prevention lies not in our system, but in ourselves. Nobody needs genetic tests to know that obesity poses risks of diabetes and heart disease. When consumers are offered a choice of health plans that feature screening and wellness programs, they generally find them attractive, but not attractive enough to pay extra. And even for those who do sign up for weight loss and exercise programs, the attrition rate is very high. People routinely overestimate their ability to control their lives and impulses.

 

Once we become sick, no matter who’s to blame, we demand everything the doctor orders, regardless of cost. The next wave of diagnostic and therapeutic technology surely can improve our health, but only if it first changes our way of thinking.