follow the money, asthma prevention edition

The Washington Post explains why prevention gets shafted when it comes to treating chronic diseases like asthma:

Both [major teaching hospitals in Baltimore] receive massive tax breaks in return for providing “community benefit,” a poorly defined federal requirement that they serve their neighborhoods. Under Maryland’s ambitious effort to control medical costs, both are supposed to try to improve residents’ health outside the hospital and prevent admissions.  But like hospitals across the country, the institutions have done little to address the root causes of asthma. The perverse incentives of the health-care payment system have long made it far more lucrative to treat severe, dangerous asthma attacks than to prevent them.

Hopkins, UMMC and other hospitals collected $84 million over the three years ending in 2015 to treat acutely ill Baltimore asthma patients as inpatients or in emergency rooms, according to the news organizations’ analysis of statewide hospital data. Hopkins and a sister hospital received $31 million of that.

This is no one specific person’s fault and I don’t mean to imply that hospitals ever set out to profit wildly off of people continuing to be sick. (At least not in this case!) It’s just that the health-care system, as in many other cases, has very little money allocated to preventing the causes of illness and its people within that system feel powerless to help change anything. Imagine if the mother in this story had access to some fraction of the thousands of dollars that were spent on her child every year to simply move to a new house that wasn’t full of asthma triggers. She’d end up saving the system money in the long term! More importantly, her poor son wouldn’t be struggling to breathe all the time.

Of course, few recurrent medical issues are as straightforward as this one and there’s no mechanism to reallocate funds that would otherwise rack up big hospital bills so that people can get better. Even a single-payer system, that holy grail of healthcare activism, wouldn’t do anything for this. One could argue that a rigorous and generous enough housing & cash assistance program could be helpful, though one would also have to ensure that the subsidized housing also stays decent enough for human habitation. Still, sometimes just paying for people to get housing keeps them out of the ER, so it seems worth it to me.

The issue of the mother’s smoking is only part of the picture here (and is another thing that wouldn’t disappear in a Medicare-for-All world), but in other cases behavioral issues like smoking make up the entirety of why someone continues to go to the hospital over and over without ever getting better. More money to follow up with people and connect them with the mental health care they need would certainly help in many cases, but in the end there’s only so much that can be done by the health care system itself. Orienting ourselves as communities and societies towards health will take much more.