With the first round of health reform under our belts, it's time to shift attention from access to the real issue plaguing the American health system: cost. The cost issue is complex, spanning payment models, medical malpractice and defensive medicine, and the specialty versus primary care debate. But I want to focus on consumers, and the broader context in which they make their healthcare decisions.

A quick look at the list of the nation's most expensive health woes — which includes heart conditions, cancer, diabetes, and osteoarthritis — and it's hard to argue that consumers aren't at least partial architects of our own fates. Improvements in nutrition, exercise, weight control, stress management, smoking cessation, and sleep can put downward pressure on both severity and costs of all of those conditions.

Health plans, employers, and even policy makers aren't blind to the need to nudge consumers towards healthier behavior. But changing consumers' health behavior is hard. Program proponents bump up against consumers' self-awareness (most people think they behave better than they actually do), their perceptions (are they willing to trade off the short-term benefits of familiar habits for the long-term rewards of healthy behavior?), and even their psychology (consumers are risk averse, experiencing the pain of failure with more intensity than the joy of success).

All of this makes behavior change extremely difficult. But it's not even the whole story.

The truth is that powerful lobbies and huge advertising dollars are aligned against consumer behavior change, especially on the nutritional front. When's the last time you saw an advertisement for broccoli, or dark leafy green vegetables? No, Madison Avenue's attention and talents are directed towards promoting mainly highly processed, calorie-dense, nutrient-poor "foods" to consumers whose taste buds can't tell the difference between a burger made from grass-fed beef versus one made with corn-fed cow parts.

You know the old data adage, "garbage in, garbage out?" It applies to people — and health systems — as well. We pay for the garbage twice: first in agricultural and petroleum subsidies that make processed "foods" cheaper than real, locally sourced foods; and second in skyrocketing health costs.

I'm not opposed to the consumer behavior change/wellness movement. If we're going to try to address the American health conundrum within our existing market-driven economy, we need consumers to learn how to make better choices for their health.

But we have to get way smarter to make it work. People selling unhealthy products and behaviors use sophisticated marketing analytics to learn precisely which messages will get the most people to embrace what they're selling. We have to sell health and wellness just as aggressively, and with just as much analytic muscle behind the scenes.

Messaging won't get the whole job done, but it's time that we stop thinking of health as being above the kind of communication that makes people "have to have" what we're selling.

This post originally appeared on the Harvard Business Review blog on May 26, 2010  http://blogs.hbr.org/cs/2010/05/prevention_and_consumer_self-m.html