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by Robin Jay, BHC Editorial Director

One might say Joseph A. Califano Jr. is a pioneer in illness prevention. When he served under President Jimmy Carter in the 1970s as the United States Secretary of Health, Education and Welfare, two of his major initiatives included childhood immunizations and an aggressive national anti-smoking campaign. Today, he serves as the Chairman of the National Center of Addiction and Substance Abuse at Columbia University (CASA), which he founded after leaving the White House.

In an exclusive interview with Behavioral Health Central, we asked Califano his opinions about the healthcare reform bills being debated in Congress, and how he feels they may ultimately impact behavioral health. Without hesitating he replied, “The bills lack the element of prevention.”

Califano continued, “I think there’s very little about prevention in the bills in the House or the Senate. We know there are things that can be done. For example, if you make cigarettes more expensive, or if you make alcohol more expensive, you discourage use, you certainly discourage excessive use, and you discourage teen initiation, which is very important over the long haul of an individual’s life. Neither bill on the floor even mentions alcohol or tobacco.”

Califano pointed to the success of the New York ban on smoking in most public places as proof that prevention works. “We know in New York City, where tobacco is made very expensive and where there is virtually no place indoors where you can smoke, there’s been an 11 percent decline in smoking in the last three years. Remarkable,” said Califano.

Knowing firsthand prevention works and that keeping costs high on potentially abused substances curbs excessive usage, Califano blasted legislators who are supporting a bill known as The Beer Act.

“With respect to alcohol, a majority of the members of the House of Represent have co-sponsored the Beer Act, which would literally repeal the tax on beer that was imposed in 1991. I call that a case of real hypocrisy and chutzpah,” said Califano. “But there are lots of other things that could be done. For example, many of our corporations and large health plans now charge more for health insurance for smokers than for nonsmokers. That would make sense. Secondly, Medicare provides free flu shots and free pneumonia shots, but not all Medicare beneficiaries go out to get those shots. If we said to those beneficiaries, ‘If you get the flu or if you get pneumonia, but you didn’t get the flu shot or the pneumonia shot, then you will pay the doctor’s bill or the healthcare bill for the ailments you got for failure to get the shot,’ we would have that percentage up to 99 percent in a few weeks.

“I think with respect to substance abuse and addiction, we need to treat alcoholism and drug abuse as the chronic diseases they are and shouldn’t wait until we have a major incident [to manage the condition]. If we know someone has an alcohol problem or a drug addiction problem, we should treat them as chronic conditions. For example, in the Medicaid program — especially for women on welfare, a large proportion of whom have these problems — we should treat these issues as chronic diseases and have the person come in under any circumstance, as we do with someone who is hypertensive or diabetic. I think we’d reduce healthcare costs and improve the quality of life for people who were treated in that way. The problem is, we have to put pain and profit into prevention. All the profit is in healthcare — that’s where you make money. We have to start putting profit and pain into prevention. And I gave you some examples of how we could do that and how it would help enormously.”

Educating Politicians about Prevention

Califano said there’s a need for the public health community to educate politicians about the importance of prevention on reducing illness and cost of healthcare, but he knows it won’t be easy. “It’s tough because Congress is enormously affected by political contributions, and the contributions come from medical equipment manufacturers, the pharmaceutical manufacturers, the American Medical Association,” he said. “We’ve obliterated the difference between for-profit and not-for-profit organizations; they’re both down there fighting for the same thing. It’s tough. Politically, it’s a very tough thing to do.

“When I started the anti-smoking campaign in 1978 and announced it when I was Secretary, I came to work the next day and people were outside in front of the building protesting because they couldn’t smoke inside of their offices anymore”

Since then, the United States has seen a dramatic change in smoking — both culturally and socially. According to Califano, we’ve cut smoking nearly in half in this country from its peak in the 60s and 70s.

“But it has also made financial sense because employers began to see that smoking employees were more expensive for them,” Califano said. “People in the real estate business began to see that if they prohibited smoking in their buildings, it was easier and cheaper to maintain them. So we need to be creative enough to see and put in place policies that will demonstrate the economic benefit of health promotion and disease prevention.”

The Important Role of the Family in Drug Prevention

When discussing illness prevention, Califano said you can’t exaggerate the importance of the family. He recently released a book called How to Raise a Drug-Free Kid: The Straight Dope for Parents. “The point is to tell parents about the times and situations when their kids are at risk, about what it’s like to be an adolescent, about the adolescent brain. Parents can do more with respect to smoking, drinking and drug use than anyone else in the country, because it’s all about getting a child through age 21. If you can get a child to age 21 without smoking or abusing alcohol or using illegal drugs, that child is almost certain to be home-free for the rest of their lives.”

Actress, mother, and children’s book author Jamie Lee Curtis is endorsing the book, “It’s a parent’s tool box for today. An individual primer to help your children navigate the difficult and contradictory messages about drugs and alcohol,” said Curtis.

For more information about How to Raise a Drug-Free Kid: The Straight Dope for Parents, go to www.straightdopeforparents.org. And, for more information about Califano’s views on prevention and healthcare reform, click on the audio player to listen to our interview with him or read the written transcript that follows. We also encourage you to watch the video below in which Califano appears on The View to offer tips on How to Raise a Drug-Free Kid.

BHC: Mr. Califano, thank you for joining us today on BHC. You and CASA must be very active in healthcare reform efforts. Can you give us your views on the current bills in Congress right now and how ultimately you think they’ll impact behavioral health?

Joseph Califano: I think there’s very little about prevention in the bills in the House or the Senate. We know there are things that can be done. For example, if you make cigarettes more expensive, or if you make alcohol more expensive, you discourage use, you certainly discourage excessive use of alcohol, and you discourage teen initiation, which is very important over the long haul of an individual’s life.

Neither bill on the floor even mentions alcohol or tobacco. In fact, with respect to tobacco, we know in New York City, where tobacco is made very expensive and virtually no place indoors where you can smoke, there’s been an 11-percent decline in smoking in the last three years. Remarkable.

With respect to alcohol, a majority of the members of the House of Representatives have co-sponsored a bill called the Beer Act, which would literally repeal the tax on beer that was imposed in 1991. I call that a case of real hypocrisy and chutzpah. But there are lots of other things that could be done. Many of our corporations and large health plans now charge more for health insurance for smokers than for nonsmokers. That would make sense. Secondly, Medicare provides free flu shots and free pneumonia shots, and not all Medicare beneficiaries get those shots. If we said to those beneficiaries, “If you get the flu or if you get pneumonia, but you didn’t get the flu shot or the pneumonia shot, then you will pay the doctor’s bill or the healthcare bill for the ailments you got for failure to get the shot,” we would have that percentage up to 99 percent in a few weeks.

I think with respect to substance abuse and addiction, if we treated (in the Medicare and Medicaid population) alcoholism and drug abuse as the chronic disease they are and didn’t wait until we had a major incident, but if we knew someone has an alcohol problem or a drug addiction problem in the Medicaid program — especially for women on welfare (a large proportion of whom have these problems) and treat the problems as chronic diseases and have them come in under any circumstance, as we do with someone who is hypertensive or diabetic, I think we’d reduce healthcare costs and improve the quality of life for people that were treated that way. The problem is, we have put pain and profit into prevention. All the profit is in healthcare — that’s where you make money. We have to start putting profit and pain into prevention. And I gave you some examples of how we could do that and how it would help enormously.

I wish I could say I had high hopes that in the course of this Senate debate a lot would be done about health promotion and disease prevention.

BHC: Payer reform would have to take place as well.

JC: Yes, that's right, because providers aren’t incentivized to talk to patients. Doctors need to be paid to talk to patients. We pay doctors to prescribe pills for them, but we don’t pay them to talk to them.

BHC: Mr. Califano, back when you were the United States Secretary of Health, Education and Welfare, what was the healthcare system like compared today? What’s probably nearly the same is the Medicare system in that it’s still an acute-care-focused system, rather than being focused on chronic disease management and prevention. What do we have to do to fix this?

JC: There’s a role for the public health community to educate politicians, but it’s tough because Congress is enormously affected by political contributions, and the contributions come from medical equipment manufacturers, pharmaceutical manufacturers and the American Medical Association. We’ve obliterated the difference between for-profit and not-for-profit individuals; they’re both down there fighting for the same thing. It’s tough. Politically, it’s a very tough thing to do.

But I do think the success of the smoking campaign — when I started the smoking campaign in 1978 and announced it when I was Secretary, I came to work the next day and people were outside in front of the building protesting because they couldn’t smoke inside of their offices anymore. We’ve had a dramatic change in smoking. Now, that change has been cultural and social. We’ve cut smoking about in half in this country from its peak in the ‘60s and ‘70s. But it has also made financial sense because employers began to see that smoking employees were more expensive for them. People in the real estate business began to see that if they prohibited smoking in their buildings, it was easier and cheaper to maintain them.

So we need to be creative enough to see and put in place policies that will demonstrate the economic benefit of health promotion and disease prevention. In that connection, you can’t exaggerate the importance of the family. I have a book that just came out called How to Raise a Drug-Free Kid: The Straight Dope for Parents. The point is to tell parents about the times and situations when their kids are at risk, about what it’s like to be an adolescent and about the adolescent brain. Parents can do more with respect to smoking, drinking and drug use than anyone else in the country, because it’s all about getting a child through age 21. If you can get a child to age 21 without smoking or abusing alcohol or using illegal drugs, that child is almost certain to be home-free for the rest of their lives.

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