What would seem impossible -- a combined program that vastly improves our national health, employs the communities with the most wretched unemployment and reduces Medicaid and Medicare costs by billions -- is quite easy. As we head toward a new job stimulus, for once, let's really do the "timely, targeted and temporary" -- and do it in a way that leaves lasting results. Hiring more nurses, teachers and police for a year -- which appears to be yet again a big plank on the upcoming stimulus plan, as it was in the last plan -- does not leave behind lasting results; to the contrary it leaves havoc. And it hardly results in even temporary jobs in the poor communities with the highest unemployment.
So let's look at what we really can do. For one example, with less than one-third of the $182 billion showered on AIG since 2008, never mind the other bailouts, dubious "stimuli" and other unconsidered reimbursements, we could halt the nation's relentless march toward millions of new diabetes cases.
This encompassing failure to undertake simple and effective things with mammoth impact is perhaps as dark a gauge of our national morass as the failure to do the complex -- like health insurance reform.
For diabetes prevention -- our most costly national health debacle -- all we have to do is undertake evidence-based strategies in the poor communities, black, white, South Asian and Hispanic, now drowning from unprecedented rates of illness. Despite all the hand-wringing about diabetes, the appalling truth is that there is no national effort, based on the conclusive evidence of how to have effective prevention, to help these crippled communities. As it happens, teaching people with pre-diabetes -- blood sugar so high that virtually all of them will succumb to the lifetime expense and horror of diabetes in ten years -- to lose modest amounts of weight and take up modest amounts of exercise is twice as powerful as standard medication in preventing the usual sad progress toward diabetes that now prevails.
The major research that proves it can be done comes from the highest imprimatur -- the National Institutes of Health. NIH spent three years -- and probably $100 million or so -- testing a "lifestyle" education approach against the usual drug approach on 3,000 pre-diabetics across the country. Not only did those who received 16 sessions of coaching and education to eat better and exercise more -- plus some follow-up sessions -- halve their risk of developing diabetes over the three years of the study, but helping them only cost $1,100 per year of diabetes delayed; medicalizing people's lives by starting them on drugs cost $31,000 per year of diabetes delayed! Results were same for all ethnic groups and for men and women.
In a nation with 54 million pre-diabetics -- and already reeling from 88,000 diabetes-related foot amputations a year -- one would think that nothing could be more imperative. Yet, even with these results proudly announced in the New England Journal of Medicine -- and the education course and "protocol" available for free on the NIH website -- almost no insurance, including Medicare and Medicaid, will pay for this completely proven prevention!
Nothing real was done about diabetes -- our major national health problem -- in the first stimulus, but look at what could be done by making real diabetes prevention a major "stimulus" focus. The original NIH prevention course was taught by professionals and largely taught-one-on-one. Right now, the Stanford University Chronic Disease Center is testing out a simpler diabetes prevention course of 10 sessions delivered by local peer educators who are trained in a matter of days. The testing is going well -- although final results are not available. In any case, as I know from long experience, training low-income people, even those who don't have a high school degree, to be peer educators to teach about health in their own communities has enormous impact; their sense of mission -- and their daily example in showing that communities can learn to improve their own health -- takes this crucial work to another plane. Of course, they get paid less than "professionals" but creating a national cadre of diabetes peer educators would create thousands of viable jobs in the poorest communities -- from Appalachia to the South Bronx -- where diabetes is concentrated even as the national savings to Medicare and Medicaid reached staggering levels.
Although costs could be further reduced by teaching diabetes prevention courses in small groups -- generally, group learning increases the impact of health education -- for the moment, let's stick with a cost of about $1,000 per prevention participant to suggest the enormous improvements in our national health which could be gained if some of the vast sums strewn about in our various bailouts, stimuli and mammoth allocations of the past few years had instead been properly focused on our worst national health problem.
Let's start, for one example, in 2008 with the $182 billion for AIG, which included receiving full price from the US Treasury for some $62 billion of the now worthless derivatives it had issued. Brief calculations shows that, with just $50 billion, less than one-third of AIG's total, you could create some 2 million $25,000 a year jobs for local health educators to teach good self-care to every pre-diabetic in the United States, thereby slashing future Medicaid and Medicare costs by truly untold billions. (And, there still would have been $132 billion left for AIG, pretty good income one would say for a company issuing derivatives actually worth nothing!)
What about the $15 billion the National Institutes of Health got in the first stimulus -- mainly for "comparative effectiveness research" to "study" the best medical procedures and approaches. Don't expect real jobs from that -- this money mainly went to bolster very well paid researchers at elite universities and research hospitals -- and, ultimately it will create almost no health since it is hardly possible to complete important research of any kind in the compressed schedule attached to stimulus money. How much better it would have been just to use that $15 billion to finally start delivering the diabetes prevention education which the NIH had already studied and already shown to be massively effective; with $15 billion, you could have fielded 600,000 local diabetes educators across the nation!
Or, let's go directly to New York City, the diabetes capital of the USA, where the full costs of diabetes already equals 10% of the city budget and an estimated 1,400,000 pre-diabetics will, without intervention, soon join the 12% of the population already diagnosed with diabetes. There, the $208 million Mayor Bloomberg spent on his own re-election campaign, could have hired 8,000 local health educators to teach some 200,000 pre-diabetics the self-care that so demonstrably curbs diabetes. You say that was his money? Okay -- coming right behind that, the federal government was willing to spend $200 million a year -- for a projected five years -- to police the city during the 9/11 terrorism trials it had inexplicably decided must take place in Manhattan federal court. While this plan appears to be withdrawn, its wastefulness certainly underscores how federal money could be put to good use; at five years of $200 million a year, New York could not only teach all its pre-diabetics proper self-care while financing some 400,000 health educator jobs -- almost enough to employ every jobless New Yorker!
Is all this as simple, productive, health-giving and cost saving as it seems? Pretty much. Sure, there will be pre-diabetics who just don't want to attend a self-care course -- and so be it -- but that's not the problem. The real problem is that the public health establishment of the United States, completely separated from ordinary people, has developed a sense of control around chronic disease -- approaching Orwellian proportions. It uses the tragedy of chronic disease to aggrandize its own powers through an approach that focuses on bans, taxation of "wrong" things, and the advent of new laws and regulations that increasingly bestow what used to considered police powers on the "public health" authorities. By contrast, an education strategy conclusively proven to be twice as effective as drugs -- and that empowers the poor, the sick and the at risk to take control over their own health -- -is not something that it will demand proceed from research to action.
Maybe one day, a President who used to be a community organizer will demand that serious health education for the poor be properly organized in a true national mission to prevent diabetes. If that ever happens, there is one more caveat: for this kind of education to really work on a wide scale it has to be taken out of "public health" departments and the medical industrial complex and be put in the hands of local community groups who have an actual mission to help their neighborhoods attain good health.