Over the past several years, the issue of health care reform has come to the forefront. While most plans floated in Congress are based on manipulation of health care need by limiting the availability and access to care, those of us on the front line of health care delivery in this country believe a different approach is necessary. Instead of focusing on manipulation of health care need, prevention should be the cornerstone of comprehensive health care reform designed to achieve both (1) cost containment and (2) maintenance of quality and availability of care.

Injury prevention, for instance, has been missing from the reform debate. Seven years ago the National Academy of Sciences declared, Injury is probably the most under- recognized major public health problem facing the nation today, and the study of injury represents unparalleled opportunities for reducing morbidity and mortality and for realizing significant savings in both financial and human terms-all in return for a relatively modest investment. That statement is still true today.

Injuries kill more than 142,000 Americans and cause more than 62 million persons to require medical attention each year. They are the single greatest killer of individuals aged 1-44 in the United States and cost the nation approximately $150 billion annually. The vast majority of injuries are due to three major causes: motor vehicles, sports, and firearms, and the majority of them are preventable, though at a cost. Unfortunately, preventive approaches to medical problems are greatly underemphasized or even nonexistent in most training programs for medical personnel.

The field of sports medicine demonstrates the impact that prevention-related research can have. Studies emphasizing the preventive approach have yielded an enormous reduction of injury rates, as well as a significant reduction in health care costs. Dr. Tom Peterson's 1970 analysis of injury rates in football led to a substantial reduction in football related injuries. Dr. Tom Pashby's research and recommendation of passive preventive measures, involving protective eye wear during racquet sports and hockey, has led to a significant reduction in eye injuries and associated health care costs.

In a study at the University of Michigan in which I was involved, our research found that 71% of recreational softball injuries were associated with sliding. In the next phase of the analysis, half the fields at the University of Michigan switched over to a practical preventive measure: break-away bases. Monitoring over 1200 games, we found that break-away bases reduced injuries by 96 percent. That and data from other sources led the Center for Disease Control to conclude that if all fields in the United States switched from stationary to break-away bases, approximately 1.7 million injuries a year would be avoided, saving $2 billion in health care costs nationally.

More attention needs to be paid by the general public and the medical profession and policy makers in the public sector to preventive interventions that are effective in reducing injury and health care costs. A better-informed public by itself would move us in this direction faster and more effectively than legislative mandates. That suggests a more prominent educational role for the medical community-conducting more research and doing more to educate citizens about prevention.

Congress could do much to enhance preventive measures by adopting the health care reform idea known as Medical Savings Accounts (MSAs). With MSAs, individuals could set aside a portion of their earnings in tax-free, portable investment accounts. From those accounts, each of us would pay our smaller medical bills ourselves, leaving high-deductible, low-premium insurance to cover mostly catastrophic events.

MSAs would be a powerful new incentive for each of us to invest in prevention because doing so would be to our personal, financial advantage. A September 1992 study from the Mackinac Center for Public Policy suggested that widespread application of the MSA idea could shave as much as $200 billion from America's annual health care bill-in part because of the preventive measures it would stimulate.

When the Golden Rule Insurance Company in Indianapolis implemented an MSA program on its own, the employees increased their use of preventive care: 20 percent of them reported using their MSA funds to purchase a preventive service they would not have bought under a traditional health insurance policy. Michigan enacted a limited state tax credit for MSAs last year, but changes in federal tax law are needed to encourage widespread adoption.

It makes both economic and personal health sense to practice prevention as the rule and not the exception. This promising approach is the next frontier for health care reform.