Section 5: Invest in Prevention

May 7, 2012 § 1 Comment

Three old American sayings capture the interconnections among personal responsibility, preventive medicine, and health care costs. Consider “You are what you eat,” and “An ounce of prevention is worth a pound of cure,” and “A penny saved is a penny earned.” If we as individuals take better care of ourselves, if we as a society take better care of ourselves, we’ll be not only healthier but also wealthier in the long run. Every Texan needs to have more skin in the health care game … especially those who have too much skin and fat already. We can no longer blow smoke at proven ways to stop people from smoking and exposing others to their secondhand smoke. We need a shot in the arm to stop the spread of deadly, contagious diseases. A healthy and wealthy Texas depends on a sound health care system with robust medical care and effective public health components. There is a legitimate role for limited government to play in safeguarding a sound, responsive public health infrastructure in Texas. All in all, a stitch in time does indeed save nine.

Encourage Texans to take personal responsibility for their own health

Texas needs to support our citizens in taking more responsibility for their health and health care decisions.

The leading causes of death and disability in Texas and the United States today are preventable because they are closely associated with personal lifestyle decisions. Texans’ personal behaviors contribute to more than 60 percent of all deaths in our state every year.

The key to maintaining health lies in helping patients assume responsibility for their own health with regular support from their physicians. Competent, compassionate medical care, delivered with professionalism, state-of-the-art clinical knowledge, and patient respect are critical components of this responsibility. Conversely, patients have a responsibility to make informed, healthy decisions.

Physicians must continue to emphasize the importance and power of personal responsibility in patients’ health outcomes. Over the past century, public health interventions have effectively reduced and, in some cases, eliminated illness and death. We must use education and preventive medicine measures to go further – to curb the need for the complex treatment required once a preventable condition develops. Each occurrence of preventable chronic disease is costly to Texas’ government and businesses, to our economy, and to our people.

Personal health and wellness depend on the behavioral decisions we make as well as the social and environmental factors to which we are exposed throughout a lifetime. Four out of 10 Texas adults report at least one factor – high cholesterol, obesity, high blood pressure, a sedentary lifestyle, or a smoking habit – that puts them at high risk of developing a chronic disease.[i] Many adults have more than one risk factor and can develop multiple chronic conditions.

These chronic diseases are killers that strike down Texans before their time. Tobacco, for instance, is directly responsible for the death of 24,000 Texans each year.[ii] This is more than homicide, HIV, suicide, influenza and pneumonia, accidents, and diabetes — combined.

Patients and their families trust their physicians to guide and influence decisions made to protect the patient’s health. However, with the massive information and misinformation in today’s super technology-driven environment, each patient and family needs the truth. Health literacy – patients’ education and ability to read, follow instructions, and communicate verbally – also affects their health. Nine out of 10 adults struggle with fully understanding basic health information as seen in advertisements, stores, the news, and in their communities.[iii]

All physicians and health care providers need to educate themselves on the cross-cultural dynamics that can impact a patient’s understanding and compliance with treatment. So, too, must the government’s education efforts evolve to accommodate the diverse cultures among poorer populations to ensure materials and programs connect with our population.

Invest in a public health-prevention infrastructure

Many of Texas’ health problems are associated with socioeconomic and environmental factors, such as neighborhood, poverty, and education level. These factors influence our health both individually and as groups. They contribute disproportionately to health disparities including premature death. Partnering with public health is a way for physicians to maximize limited resources and capacity, and address factors in Texas communities that influence health.

The increase in the number of older Texans during the coming decades will have dramatic consequences for public health, the health care financing and delivery systems, informal caregiving, and pension systems. More older adults and increasing chronic disease will further strain resources in Texas counties where basic public health concerns (e.g., control of infectious diseases and maternal and child health) are yet to be addressed fully.

Complicating matters is the largely ignored public health framework of previous decades. Public health functions such as disease registries and surveillance systems have not kept up with the accelerated changes of health information technology. Many registries and systems, therefore, are not widely accessible nor do they contain data that are timely enough for effective intervention.

As Congress and the Texas Legislature have tried to reduce overall health care spending, they unfortunately have reduced funding for medical education and population-health-focused infrastructure as well. Health disparities may be reduced by increasing the number of ethnic minorities working in health occupations; this will become especially important as the minority population in Texas grows. As the primary advocate for patients, TMA is concerned about our ability to provide care in general, but particularly to these traditionally underserved communities.

Savings From Every $1 Spent on a Vaccine[iv]



Diphtheria, tetanus, pertussis


Measles, mumps and rubella


Perinatal hepatitis B




Haemophilus influenza B




Physicians face many challenges in caring for patients who present with preventable illnesses and complications. Physician participation in local and state efforts to improve health literacy and public health education programs could enhance the effectiveness of these programs substantially.

Invest in preventive care for low-income women

Lost in the highly charged political debate is the fact that “women’s health” includes far more than abortions. If Texas and the federal government cannot resolve their differences, the state must continue to find a way to finance the Texas Women’s Health Program.

The Women’s Health Program, which does not provide abortions, delivers cost-effective basic health care screenings — such as for cancer, high blood pressure, and diabetes — as well as birth control. This is the only source of such preventive care for many low-income women in Texas.

More than 70 percent of pregnancies among single young women in Texas are unplanned.[v] Increasing the number of women who enroll in the Women’s Health Program after a Medicaid delivery is especially important. Women who have had a Medicaid-funded delivery are at particularly high risk for subsequent pregnancy, often so soon that risks of prematurity and low birth weight are elevated. Babies born too soon or too small often have significant health problems, such as respiratory or developmental delays, contributing to higher medical costs at birth and as the child ages. In 2007, unplanned Medicaid births cost the state more than $1.2 billion.[vi]

Increase immunization by reducing barriers for all Texans

Vaccines are some of the safest and most cost-effective ways of preventing infectious disease. Texas has made great strides in the last few years in vaccinating young children. In 2010, an estimated 75 percent of Texas children aged 19-35 months had received the recommended series of vaccinations.[vii] We must continue our work protecting children and adults in Texas from preventable and potentially fatal diseases.

Properly vaccinating all children born in the United States would prevent more than 14 million cases of disease during their lifetime and 33,500 deaths.[viii] The Centers for Disease Control and Prevention (CDC) says every dollar spent on a childhood vaccination saves $6.30 in direct medical costs. Adding in the costs of lost work time, disability, and death, brings the return on investment to $18.40 for every dollar spent.[ix]

Texas needs a strong public and private immunization infrastructure for all Texans from infancy until well past 65 years. We must make substantial progress over the next decade to meet national vaccination targets.

With legislation passed in 2011, Texas is set to lead the nation in ensuring health care workers are properly vaccinated and do not spread preventable diseases to patients.

Texans depend on their physicians and their medical home to stay up to date on their vaccinations. But Texans are mobile and their insurance coverage changes, so we need a statewide immunization registry with information on vaccinations of all Texans.

With more than one in four Texans uninsured, Texas needs a strong local and state public health system to complement the vaccinations that physicians and other health care workers provide.

Older adults are especially vulnerable to infectious disease, thus the state must continue to promote immunizations such as pneumococcal vaccine for these individuals. The Texas Department of State Health Services has identified bacterial pneumonia as one of the top three potentially preventable hospitalizations in Texas. Combined efforts of physicians, providers, government officials, and community organizations have been shown effective in reducing the number of potentially preventable hospitalizations due to infectious diseases. These efforts should be enhanced. (See Section 3 for more details.)

Invest in obesity control

Overweight and obesity contribute to diabetes, hypertension, heart disease, cancer, and stroke. Texas has an easy-to-see obesity crisis. Some 66 percent of Texas adults are obese; the United States average is 63 percent. During the past three decades, obesity rates in children have more than tripled in the country. Today, 32 percent of Texas children (ages 10-17) are obese.[x]

Percent of Children Whose Weight Status Is at or Above
the 85th Percentile for Body Mass Index


The obesity epidemic, and the ever-younger age groups that it strikes, threatens Texas’ physical and fiscal health. Texas’ continually expanding waistline correlates to our health care cost demands. Obesity is responsible for 27 percent of the growth in health care spending. Treating obese patients costs 37 percent more than treating normal-weight patients.[xii]

The rise in overweight and obesity is affecting the bottom line of Texas employers. The Texas Comptroller’s Office found that in 2009, obesity cost Texas businesses an estimated $9.5 billion, due to higher employee insurance costs, absenteeism, and other effects. Left unchecked, obesity could cost employers $32.5 billion annually by 2030.

Total Projected Obesity Costs to Texas Businesses, 2009-30
(in billions)


Improved physical health in students has been linked to academic success. Conversely, children with obesity are more prone to absences and lower grades. In the United States, students who are physically active at least 60 minutes on most days, play on at least one sports team, or watch fewer than three hours of television per day consistently have “mostly A’s.”[xiv]

A great proportion of obese adults were overweight or obese as children. This serious risk factor is found in Texas, where more than 30 percent of children in grades 4 through 11 are overweight or obese.[xv] A child who is overweight at age 12 has a 75-percent chance of being overweight as an adult.[xvi]

There is no single solution to preventing or addressing obesity. Multiple evidence-based approaches must be pursued for physicians, communities, schools, and workplaces, and each must identify potential barriers to implementing local programs.[xvii]

Invest in tobacco cessation

Texas pays a high price for tobacco addiction. Each Texas household pays an average of $568 in state and federal taxes each year for smoking-related costs.[xviii]

Annual Medical Savings by Condition for Each Smoker Who Quits


Annual Savings

Coronary health disease and stroke


Childhood asthma


Low birth-weight babies


Other childhood respiratory conditions


Childhood otitis media


Adult pneumonia


Annual Total


The direct and indirect costs to Texas businesses from tobacco use are significant, and there are significant medical savings when a smoking worker stops smoking. For Texas businesses, “smoking cessation is the gold standard of health care cost effectiveness.”[xx] America’s Health Insurance Plans and Kaiser Permanente developed a return on investment calculator for health plans and employers that helps employers understand the cost-effectiveness of different types of tobacco cessation programs, up to $197 per $1 invested over five years.

More than 24,000 Texans die each year from smoking-related illness. Tobacco is the single greatest cause of preventable and premature death and illness in the world.[xxi] Adults who smoke are at substantially greater risk of developing chronic diseases and conditions including multiple types of cancer, increasing their risk of diabetes complications, cardiovascular disease, and stroke. Children exposed to secondhand smoke are more likely to develop respiratory problems and acute illnesses. Almost every major system in your body is affected by smoking or secondhand smoke.

In 2012, total revenue to Texas from tobacco taxes and fees and tobacco settlement funds is expected to be $1.9 billion. But Texas will spend less on tobacco prevention in 2012 than most other states, ranking 39th in the nation for tobacco prevention expenditures. CDC recommends that Texas spend $266 million on tobacco prevention to have an effective and comprehensive tobacco prevention program. In 2012, Texas will spend a paltry $6 million in state funds on tobacco prevention.[xxii]

So far, 30 states have passed smoking bans in restaurants and workplaces. About 40 percent of the Texas population is protected by 100-percent smoke-free local ordinances. Thirty-three Texas cities and towns prohibit smoking in all bars and restaurants and non-hospitality workplaces (2011), but many areas of Texas do not have a smoking ban. [xxiii] Texas communities that implemented these bans are, in effect, subsidizing health care services in those areas that have not adopted similar bans.

Almost three-fourths (70 percent) of Texans favor a statewide ban on smoking at the workplace and public buildings.[xxiv] Personal liberty arguments against such ordinances ignore and overlook the rights of non-smokers and Texas taxpayers who are burdened with the poor choices of some. Texas must be freed from this unnecessary cost and addiction.


  • Actively involve patients in the health care decisionmaking process.
  • Promote participation in smoking cessation programs, worksite wellness, and routine screenings.
  • Provide incentives via merit grants that recognize those state agencies that are promoting productive worksite wellness efforts.
  • Continue full funding for the Texas Women’s Health Program.
  • Streamline efforts to vaccinate people who work with high-risk populations.
  • Support statutory changes that allow parents of Texas schoolchildren access to data specific to the schools their children attend regarding the number of conscientious objector claims to vaccination.
  • Improve access to vaccinations, including improvements in the state’s Vaccine for Children Program and the adult safety net programs; this will ensure uninsured and low-income persons can get appropriate vaccinations.
  • Keep public health disease surveillance systems robust.
  • Increase funding for improving access to healthy foods; increase access to parks and recreational facilities; and promote worksite wellness policies.
  • Improve the health of Texas students by increasing physical activity and reducing barriers to student participation in safe school sport activities.
  • Promote physician participation in school health advisory committees and other public health prevention programs. Support legislation that requires inclusion of a primary care physician on all school health advisory committees.
  • Require Texans who smoke and communities that allow it in public venues to fund an increasing portion of health care costs related to smoking-related illnesses.
  • Adequately fund proven interventions to reduce tobacco use, such as Texas’ Quitline and education in schools.
  • Provide smoking cessation benefit coverage for state employees and retired teachers.
  • Support legislation that would require public workplaces, venues, and restaurants to have an indoor smoke-free policy.

[i] Bureau of Disease, Injury and Tobacco Prevention. Texas Department of Health. Cardiovascular Disease in Texas: A State Plan with Disease Indicators and Strategies for Action. Available at  Accessed April 2012.

[ii] Texas Department of State Health Services. Mental Health & Substance Abuse Division. Tobacco Prevention & Control Strategic Plan for 2008-2013. July 2007. Available at  Accessed April 2012.

[iii] U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. National Action Plan to Improve Health Literacy. June 2010. Available from Accessed April 2012.

[iv] Adapted from Every Child By Two: Economic Value of Vaccines. Available from Accessed April 2012.

[v]Texas DSHS communication; average for 2004-06.

[vi]Based on data provided by Texas DSHS for 2007: HHSC average Medicaid birth cost.

[vii] The Henry J. Kaiser Family Foundation. State Health Facts. Texas: Childhood Immunizations. 2010. Available at  Accessed April 2012.

[viii] Zhou F. Updated economic evaluation of the routine childhood immunization schedule in the United States. Presented at the 45th National Immunization Conference. Washington, DC; March 28–31, 2011.

[ix] Rapoport, Ross. Cox News Service. CDC: Immunizations High But Shot In Arm Still Needed August 2003.

[x] The Henry J. Kaiser Family Foundation. State Health Facts: Texas. Health Status. 2010. Available at  Accessed April 2012.

[xi] 2007 National Survey of Children’s Health

[xii] Finkelstein, Eric et al. Annual Medical Spending Attributable To Obesity: Payer-And Service-Specific Estimates. Health Affairs, 28, no.5 (2009):w822-w831.

[xiii] Wangrin, Mark. Gaining Costs, Losing Time: Costs Grow Along With Waistlines. Fiscal Notes. July 2011. Available at Accessed April 2012.

[xiv] Center for Disease Control. Physical Inactivity and Unhealthy Diet Behaviors and Academic Achievement. Available at  Accessed April 2012.

[xv] Arons, Abagail. Childhood Obesity In Texas: The Costs, The Policies, and a Framework for the Future. January 2011. Available at Accessed April 2012.

[xvi] Childhood Obesity in Austin, Texas. Available at  Accessed April 2012.


[xviii] Campaign for Tobacco Free Kids. The Toll of Tobacco in Texas. March 2012. Available at Accessed April 2012.

[xx] AHIP. Making the Business Case For Smoking Cessation. Available at Accessed April 2012.

[xxii] Robert Wood Johnson Foundation. A Broken Promise to Our Children: The 1998 State Tobacco Settlement Thirteen Years Later. November 2011. Available at  Accessed April 2012.

[xxiii] American Nonsmokers Rights Foundation. Percent of U.S. State Populations Covered by 100% Smokefree Air Laws. April 2012 . Available at Accessed April 2012.

[xxiv] Campaign for Tobacco-Free Kids. Voters Across The Country Express Strong Support For Smoke-Free Laws. Available at Accessed April 2012.

§ One Response to Section 5: Invest in Prevention

  • Ridg Gilmer says:

    I find the COD in TX – 2008 chart confusing (p37). Tobacco is stated to be the leading killer, yet lung cancer isn’t charted. Annual Medical Savings chart (p41) lists nothing for prevention of lung cancer. (?)
    Obesity control is the major project of the current Council on S&PH, yet this is not listed as a specific TMA Recommendation. (Several indirect recommendations are given.)

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