Nearly all of us have known someone who has had a heart attack or heart surgery, and we probably are astounded at the cost of their care.

Maine also has a tremendous number of people with lung disease who often need $1,000 per month for medicines and expensive hospitalizations several times a year. Our state budget pays for a lot of these people through Medicaid, state employee plans and state retiree insurance.

These diseases could be reduced greatly if people stopped smoking, ate the right foods and exercised.

We also spend public money on community and public health efforts to prevent these and other chronic diseases. We’ve worked to prevent sales of tobacco to minors, expand healthful food options for elderly and low-income people, regulate toxins in the workplace, develop new paths and trails for walking, maintain safe levels of fluoridation in public water supplies and increase rates of cancer screening.

However, a quiet struggle is going on in Augusta as to which is the better investment. This is evident in state budget and staffing decisions. We know what we’re getting when we spend public money on medical care; what are we getting when funding prevention efforts?

Health care spending in Maine totals about $11.1 billion, fifth highest per capita in the country (Kaiser Family Foundation, 2015). Spending on public health and prevention barely reaches 1 percent of that total. A sizeable proportion of the prevention money comes from the national tobacco settlement funds. Since 1999, these funds have been a shot in the arm to public health without burdening the state budget. The Legislature at that time created the Fund for Healthy Maine, into which between $40 million and $60 million have been deposited each year from the settlement.

In Maine, those tobacco settlement funds have gone to a wide range of programs, addressing such issues as substance abuse, tobacco use, obesity, oral health and early childhood interventions. About a third of the prevention funds over the years, however, has been drained off for other purposes in the state budget. The LePage administration recently proposed taking even more funds for nursing home expenses and physician fee increases.

The underlying philosophy in these budget proposals is that public health spending is wasteful and ineffective, so let’s divert funds into medical priorities that are more pressing and more tangible. The urgency is clear — one can hardly argue against the importance of nursing homes or physician care.

Are public health efforts a good use of our limited resources? Are they producing results?

In the past 15 years, youth smoking rates in Maine have been reduced by 48 percent and adult rates by 24 percent. Eighteen percent more elementary students reported eating five or more servings of fruits and vegetables in just a four-year period (2009-2013). The alcohol use rate has declined by 44 percent since 2001. Teen pregnancy rates have moved from among the highest in the nation to among the lowest during the past 17 years.

Do we ask the same questions of the medical field? Atul Gawande, a surgeon and notable writer about the U.S. health care system, would say not enough. In his recent New Yorker article, titled “Overkill,” Gawande cites a large body of research showing that “millions of people are receiving drugs that aren’t helping them, operations that aren’t going to make them better, and scans and tests that do nothing beneficial for them, and often cause harm.”

He muses about our need to shift health care resources, and then poses a couple of difficult questions. Do we have the courage to withhold treatment of urgent conditions — for example, some cancers — when there is no improvement in survival rates? Do we have the courage to allow prevention to take its course even when results are way down the road?

Budget decisions are about the here and now — there is rarely time or ability in two-year state cycles to think long term. It is hard to wait for the anticipated returns on prevention spending when we get slammed with the next health care budget disaster.

But remember, we spend 99 times as much on medical care as on prevention. Can we afford to allow that tiny proportion to wither even further in the face of all-consuming medical expenses? Is that the kind of priority we want for our residents, families and communities? Can’t we at least spend 1 or 2 percent on preventing these diseases?

When billions of dollars are churning through our state health care system, sometimes for questionable care, we should be as vigilant in demanding accountability in medicine as we are in public health. After all, as Willie Sutton, the famous bank robber, would say, “That’s where the money is.”

Lisa Miller, of Somerville, is a former legislator who served on the Health and Human Services and Appropriations and Financial Affairs committees.

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