I'm delighted that President Obama has said he will not sign a health care bill unless it includes an emphasis on efforts to prevent disease as a way of cutting the future costs of health care. But where would all the money come from to pay for such preventive services?

Just off the top of my head, here's one possible source of "extra" cash: the large amounts of money currently paid out for angioplasties, which widen and prop open narrowed coronary arteries. Such procedures are indeed beneficial and justified in people whose severe or disabling chest pain (angina) continues despite medications; however, studies have now shown that preventive lifestyle measures and drug treatment to lower LDL cholesterol and control blood pressure are every bit as effective as angioplasty for those patients whose coronary heart disease is chronic and stable.

Why do so many cardiologists continue to carry out angioplasty procedures on so many of the patients who could be treated at a much lower cost?

Frankly, part of the answer lies in the financial rewards to be gotten from performing a great many angioplasties. Physicians are healers, true, but they must also be businesspeople. And like everyone else, they need to support their families and pay for their rent--and, unlike most, they must also pay their secretaries to waste countless hours filling out insurance and other forms that are part of our medical care (non)system.

But clearly, prevention is more sensible, and probably less costly. To prevent diabetes, for example, by slowing or stopping the obesity epidemic makes more sense than treating people who have already developed obesity.

Rich Hamilton, director of public relations for Trust for America's Health, made some valuable recommendations about prevention recently in his written testimony to a subcommittee of the House Agriculture Committee. He cited the need to improve nutrition and to increase physical activity, and I agree completely.

Nutrition can be improved in schools by mandating lower-calorie and more nutritious lunches and snacks, as well as by eliminating high-calorie drinks and other unhealthy products in school vending machines.

Hamilton also mentioned several successful community programs that have built bicycle and walking trails, improved sidewalks, and enabled better access to fresh produce through farmers' markets, but I'm less enthusiastic about spending billions of dollars a year for new infrastructure projects. I'm not hot on such projects because I believe that laziness, and not a lack of facilities, explains the failure of people to exercise. Suburban and rural areas already have plenty of trails and places to ride a bike or walk. And inner cities have plenty of sidewalks, though some may be too fearful of crime to walk and jog on them.

But I heartily endorse another recommendation of Trust for America's Health--that preventive medical services get the funding they need and deserve. One place where our medical (non)system is badly broken is in how insurance companies are usually ready to pay for expensive treatment interventions and surgical procedures but then limit payments for the time spent by physicians, dieticians, and others to provide preventive advice and services. Some of the projected savings from preventing disease should be ploughed back into paying for those very preventive services offered by health care providers.

Unfortunately, the reasons why preventive services aren't being offered go even deeper than a failure to pay for them. Medical school teaching and residency programs for newly hatched physicians focus largely on understanding and treating disease, rather than on preventing disease. This is why too few of our present physicians are prepared to provide preventive advice and services, even supposing that they had the time and were properly reimbursed for such efforts.

The whole philosophy behind medical education will need to change, and proper compensation must be earmarked for preventive measures, before future physicians will be able and willing to provide useful preventive help.