There is much to be hammered out before a final health reform bill emerges from Congress. Disputes over the public plan, abortion, financing and when reforms will actually take effect continue to delay progress. But on one thing, apparently, there is broad consensus: Nearly everyone supports prevention. In fact, a recent poll found that 71% of Americans favor increased investment in disease prevention and believe it will save money in the long run.

Prevention is a broad concept, encompassing everything from flu shots to prostate screening to smoking bans to confronting racism. And just because Americans say they favor increasing funding for “prevention” does not mean they all envision the same approach. Some personal-responsibility advocates, for example, throw their support behind pay-to-play prevention efforts—like increasing insurance premiums for people who smoke or are overweight. Others, like Senator Barbara Mikulski, believe the most important investment in prevention is to guarantee access to routine screening tests—mammography, Pap smears and colonoscopies—even if evidence suggests this may not always be the case.

My internist is betting that his privately insured patients will make their own investment in yet another view of prevention and enroll in his new “concierge medical practice.” He recently notified long-time patients that he will no longer accept their insurance. Instead, he is asking patients to pay $1500 cash to stay in his practice and receive “preventive” care (dietary counseling, a yearly physical, blood pressure measurement, vaccines). Anything extra—like an urgent care visit when you’re actually sick—requires you to pay out of pocket and attempt to get reimbursed by insurance on your own. At its most extreme, this concierge-style focus on prevention can cost $15,000 or more and include services like whole body scans and personal genome testing.

Such preventive medicine for the well-heeled and worried well is the type we read about most often in self-help magazine articles. But prevention on a larger scale is something altogether different—it will require tackling the fundamental health disparities that, for example, cause infant mortality rates for black babies to be twice the national average. It will require confronting the fact that twice as many African-Americans will be diagnosed with diabetes this year and that people living in the most deprived neighborhoods have a 22 percent higher risk of dying, regardless of their diet and lifestyle. These kinds of disparities vary by state and by region; with rural areas and urban centers having the most intractable problems. But the fact is that for prevention to be effective, it must move away from concentrating solely on medical factors and consider the larger socio-economic issues facing minority and low-income populations.

Prevention is a stated goal for President Obama’s broad concept of health reform. Clearly, the expansion of Medicaid, employer mandates and the government-funded subsidies for purchasing health insurance will provide more health benefits for minorities and other lower-income people who have traditionally been unable to afford care. More funding for community health centers, which currently serve 17 million patients, 40% of whom are currently uninsured, will also expand access to care. In the health care equation, that means the uninsured will be able to better access primary care and preventive services instead of waiting until they are already very sick to see a doctor.

Sounds good, but it turns out that just providing access to care will not solve health care disparities when it comes to chronic disease. Medicare, which extended coverage to all senior citizens, is still plagued with glaring inequalities; black and Latino beneficiaries have higher rates of chronic diseases like hypertension and diabetes and continue to have shorter life expectancies than their white counterparts. They suffer renal disease, heart failure and other end-stage complications of chronic illness at higher rates as well.

What this tells us is that access to primary care and standard preventive services is not enough. Both Congressional health bills would go further in trying to provide more equity in prevention of disease. The Senate bill includes the Prevention and Public Health Fund that would provide funding for evidence-based prevention and public health programs. The bill would also remove cost-sharing for key preventive services covered by Medicare and Medicaid. The House bill would provide $34 billion for a Prevention and Wellness Trust that would support public health programs at the state and local level. There are also provisions for doing a better job on collecting racial, ethnic, economic and language data on patients—at least those covered under federal programs.

These are important efforts—especially the emphasis on “evidence-based prevention and public health programs.” Because the truth is, prevention does not always pay off—both in terms of health consequences and in economic terms. You can invest in community health centers and send out a legion of health educators to tell folks about diet, exercise, quitting smoking and having safe sex—but you might only have a minor impact on preventing disease. If  there is nowhere to exercise safely in the community, if fresh produce is expensive and hard to find, if people are unemployed, suffering mental distress, facing the threat of losing their homes, confronting language barriers or cultural incompetence from providers, these interventions will have limited effect.

In the current Hastings Center Report, Erika Blacksher takes the wider view of prevention. She writes, “Like most Americans, I am a fan of prevention. My view of what prevention is, however, may not be widely shared. Prevention to my mind means assuring that all persons are able to live in safe, clean houses and neighborhoods; eat healthy foods; socialize with family and friends; get exercise; rest and manage stress. Prevention in this sense is ‘primary,’ in that it aims to prevent disease and promote health by creating social and environmental conditions associated with health and well-being.”

Blacksher continues, “In the absence of efforts that address the social and environmental determinants of health, those who are at risk or sick are very unlikely to improve their health outcomes. Moreover, nothing will slow the rate at which new people enter the at-risk population. Some forty million Americans are projected to join the ranks of the chronically ill by 2030.”

It’s easy to get discouraged when confronted with such stark statistics. Health reform is a giant enough undertaking without thinking about solving racism, poverty and other vast social ills. That’s why this recent story from the New York Times is so encouraging. In it, reporter Erik Eckholm, tells the remarkable story of Dane County, Wis., where “the implausible has happened: the rate of infant deaths among blacks plummeted between the 1990s and the current decade, from an average of 19 deaths per thousand births to, in recent years, fewer than 5.”

“‘This kind of dramatic elimination of the black-white gap in a short period has never been seen,’ Dr. Philip M. Farrell, professor of pediatrics and former dean of the University of Wisconsin School of Medicine and Public Health, said of the progress.

“‘We don’t have a medical model to explain it,’ Dr. Farrell added, explaining that no significant changes had occurred in the extent of prenatal care or in medical technology.”

The Times piece gives the example of Brandice Hatcher, a 26-year-old pregnant woman who had spent her first 18 years in foster care and had little idea of how to access prenatal services.

“Over the summer she started receiving monthly visits from Laura Berger, a county nurse, who put her in touch with a dentist. That was not just a matter of comfort; periodontal disease elevates the risk of premature birth, increasing the levels of a labor-inducing chemical.

“Ms. Hatcher had been living in a rooming house, but she was able to get help from a program that provided a security deposit for her apartment. She attained certification as a nursing assistant while awaiting childbirth.

“Under a state program, a social worker visits weekly and helps her look for jobs. And she receives her prenatal care from the community center’s nurse-midwives. A church gave her baby clothes
and a changing table.”

The article explains that although traditional medical models don’t explain the dramatic drop in Dane County’s infant mortality rate, the wider definition of “primary prevention” does. “[T]he decline appears to support the theory that links infant mortality to the well-being of mothers from the time they were in the womb themselves, including physical and mental health; personal behaviors; exposure to stresses, like racism; and their social ties.” Complex theory, but really, quite straightforward and practical solutions had huge effects.

Traditional medical models also fall short when talking about AIDS prevention—another disease that disproportionately affects minorities. Minorities represent more than half of all AIDS cases in the U.S., and black and Hispanic women are the fastest growing population among those who are HIV positive. Take the recent findings of the Brooklyn AIDS Task Force, a community-based organization that provides HIV counseling and testing, primary care, needle exchanges and other programs to ethnic and racial minorities at high risk of infection. While conducting research to help draw up a new strategic plan, the organization discovered a new, preventive service that would benefit their clients: affordable housing. It turns out that being homeless or marginally housed is a major risk factor for contracting AIDS in Brooklyn—and likely, elsewhere. Having permanent, affordable housing is just as important in preventing disease in BATF’s clients as having access to primary care, HIV testing and clean needles.

If Americans really support investing in prevention then we will have to go further than expanding access to health care. We will have to invest in innovative programs like the ones in Dane County and Brooklyn that look outside the medical model in preventing disease and resolving health disparities. It’s only by figuring out the root causes of health disparities that we can develop effective programs and true prevention can really take place.