Prevention is one of those things that everyone can agree on, the health policy world’s equivalent of apple pie (minus the fat and sodium). Except that nowadays, health care is so politicized that no one can agree on anything. Less like apple pie, more like broccoli.

It’s not that people don’t like prevention and public health—or even broccoli.* They do. They even think it’s worth spending money on—up to a point. It’s too soon to know whether that traditional support for spending on prevention survives the current intense focus on budget cutting.

Preventive care, of course, can mean different things to different people—from promoting health and preventing disease through proper diet, exercise, immunization, and good primary care; to screening, which may not prevent a disease but can prevent it from advancing to a more dangerous state; or it may mean “population” health, which could include things like having walkable neighborhoods and safe places for kids to play.

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Interested in prevention and public health? Don’t miss the next Altarum Health Policy Forum Roundtable discussion, “Public Health, Wellness, and the Prevention and Public Health Fund: How Health Reform Seeks to Transform Health Care and Reduce Costs” March 29 at the Pew Center. Find out more at www.altarum.org.

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Depending on how you define prevention, it may or may not save money—or it may save, but not in those five- and ten- year budget windows that Washington operates on. Staving off serious chronic diseases like diabetes is a money-saver, but not the day after tomorrow.

Most of the politicking around health care right now is about the price tag, and the role of government. Nobody is going to the House floor and declaring, “Let’s repeal prevention and have everybody get sick.” But the Patient Protection and Affordable Care Act includes major initiatives on prevention, direct and indirect, broadly defined. Repealing or defunding health reform would mean repealing or defunding those programs, too.

While Americans are deeply and quite bitterly split on health reform, they have pretty positive feelings in general about prevention and public health, and generally think it’s something that we as a country should spend money on. Some public opinion surveys in November 2009—a heated time politically, right before the Senate vote on health reform—and focus groups in 2010 found support for public health and prevention across party lines.

Robert Blendon, a professor at both the Harvard School of Public Health and the Kennedy School, has analyzed public opinion on prevention and public health and detected some themes. People do see the government as effective in combating infectious disease. They are less confident that the government can do as much to make the overall population healthier, or tackle chronic disease.

“People like the idea (of prevention), but they aren’t sure the government is very effective. They are not sure that the government knows how to change people’s behavior or change chronic disease,” Blendon said. The partisan divide on whether to spend money on government prevention programs is “40 miles wide,” he said, with Republicans more skeptical. “It’s popular in the abstract but there are real issues about spending money to change people’s behavior.”

The split may be even deeper now than just a few months ago, because of the growing intensity of the focus on the deficit and government spending. There hasn’t been a lot of debate, specifically, about the impact of defunding health reform on public health. But if the PPACA goes, so goes the Medicare preventive health benefits, the Prevention and Public Health Fund, and the National Prevention Strategy, still being developed.

The Public Health and Prevention Fund, in particular, includes $15 billion over the next 10 years for public health programs, including $500 million last year and $750 million this year. By 2015, $2 billion will be available annually—if it survives the red-ink hunt. It is certainly quite possible that those funds could be trimmed, or even cut deeply, in the coming rounds of federal spending cuts.

Some of the fund money has been directed at expanding the primary care work force (which not everybody in the grass roots, community based branches of preventive health field saw as “preventive care”). But it also went to community prevention, including anti-tobacco efforts, programs to improve nutrition and increase physical activity, and other community-based strategies against heart disease, diabetes, and cancer. Some of the funds went for “clinical prevention,” including immunizations. Some is for the public health infrastructure, including preparing for detection and response to infectious disease threats. And some is for research and tracking, which is part of monitoring our collective health.

Whether people understand that these new and expanded programs are derived from health reform—or whether they even know they exist—is not clear. Democrats keep hoping that health reform will grow more popular as people see it in action, but a) that hasn’t happened yet and b) some of the political rhetoric has implied that people will be able to keep the popular parts of the health law (like the ban on pre-existing conditions) and get rid of the unpopular parts (like mandates). It’s a bit like telling people that if they eat apple pie they will get the health benefits of broccoli.

Public priorities on preventive health can shift, as Blendon learned when he looked back at historical survey data. For instance, influenza was a big concern in 2009. That’s not a surprise; both the Asian bird flu and the H1N1 “swine” flu were in the news. It’s probably a pretty safe bet that flu would not be quite as much of a priority in a 2011 survey. Cancer has topped public concerns recently, followed by heart disease, and HIV/AIDS. But in 1940, syphilis—even more than cancer or polio—was what was on the public’s mind. Concerns do indeed shift with time.

A snapshot of current public health priorities would show that anti-tobacco programs have dropped as a public concern, maybe because smoking rates have dropped and people think the problem is “solved.”

Obesity, however “has moved up the agenda,” said Blendon. It is increasingly seen not as an issue of personal responsibility, but as a public problem, related to school lunch, recess and exercise policies, advertising, and other aspects of public life and culture.

Of course, given some of the attacks by Sarah Palin, Rush Limbaugh, and others on the right on First Lady Michele Obama’s “Let’s Move” Campaign, we haven’t reached a complete consensus on childhood obesity either. (Some Republicans, notably former Ark. Gov. Mike Huckabee, have defended Obama’s initiative).

Maybe one day Mrs. Obama will just say, “Let them eat Broccoli.” For now, we’re left with debate and a wavering public opinion.

*Broccoli, you may recall, wended its way into Judge Roger Vinson’s decision that the health reform law is unconstitutional. He reasoned that if the government can force people to carry health insurance, they can force people to buy broccoli, too.

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Contributing Writer Joanne Kenen writes monthly news features for the Health Policy Forum discussing health policy innovation and “what works” in our health care system, as well as the politics of health policy and reform. As a leading nonprofit health care research and consulting institute dedicated to improving human health, Altarum encourages open discussion and debate about the many challenges in health care today. All postings to the Health Policy Forum (whether from employees or those outside the Institute) represent the views of the individual authors and/or organizations and do not necessarily represent the position, interests, strategy, or opinions of Altarum Institute. Altarum is a nonprofit, nonpartisan organization. No posting should be considered an endorsement by Altarum of individual candidates, political parties, opinions, or policy positions.