As lawmakers divvied up billions of dollars last year to address the nation's fiscal crisis via the 2009 American Recovery and Reinvestment Act (ARRA), they did not skimp on funding health. About one of every six and a half ARRA dollars went to programs at the U.S. Department of Health and Human Services (HHS)—the single largest allocation for any federal agency. Less than 1 percent of those monies, however, are going toward keeping people from getting sick in the first place.

The HHS's $122-billion allotment has been spread among the U.S. Centers for Disease Control (CDC), the National Institutes of Health (NIH) and the Administration for Children and Families (ACF) as well as other groups that fund everything from cancer research to Head Start programs for children.

But not every cause was funded equally: The lion's share ($87.3 billion) went to established health care, which includes money for pricey programs such as Medicaid reimbursement and physician education. More than $25 billion was allocated for improving health care information technology, much of which is aimed at encouraging the national adoption of electronic medical records. At the bottom of the HHS's stimulus funding list, receiving less than 1 percent of the agency's ARRA funds, is the category of prevention and wellness—a bracket that includes programs for providing vaccinations, promoting healthful diets, and countless other government efforts to keep the doctor away.

The small fraction still amounts to about $1 billion, a number that is not trivial in the field. "We are delighted that Congress recognized the importance of prevention," says Donna Brown, government affairs counsel for the National Association of County and City Health Officials. "Since the government health agencies are chronically underfunded, we were delighted to get what we got and believe it is being put to good use."

Many involved in public health and health care economics, however, think that $1 billion is hardly a meaningful boost for prevention, the root of the nation's physical and fiscal health.

Nearly half of all Americans (about 133 million) have one or more so-called chronic conditions, which can include obesity, diabetes and other ailments. As noted in a House bill introduced in July 2009 (and currently in committee), to increase overall federal funding for prevention some 75 percent of U.S. health care spending goes toward "treating patients with chronic disease." And as the authors of the bill hasten to point out, "The vast majority of these diseases are preventable." These conditions also account for about 70 percent of deaths in the U.S., yet prevention commands only about 0.01 percent of the overall health care costs, notes Wayne Giles, director of the CDC's Division of Adult and Community Health.

Investing wisely
Given the small budget this field has traditionally had, "these are historic levels of funding," Giles says of the stimulus funds aimed at preventive health. And as societal investment strategies go, putting money into preventive health causes, such as public health campaigns to encourage exercise or childhood immunizations, has been shown to pay off big in the long run, with both dollars and lives saved. Giles calls prevention "one of the best buys."

From an economics perspective, the value holds true, too. "The return on investment is potentially enormous if you use the money appropriately," says Dana Goldman, director of the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California.

In fact, an extra $10 annual investment in prevention per person in the U.S. ($3 billion a year) would amount to a savings of about $16 billion each year in health care costs, according to a 2008 report sponsored by the Trust for America's Health, a nonprofit public health advocacy group. And if that calculation is extended to benefits outside of the medical realm, such as increased working days and productivity, the payoff is likely to be greater, the report authors note.

Goldman, whose research has highlighted the per-person savings of avoiding preventable diseases such as hypertension, explains that increased prevention means that "people will have longer, more productive lives," he says, which translates into a more productive economy, as well.

Many of the dividends of prevention—both in health and economics—however, will not be seen during the life spans of ARRA-sponsored projects. And that aspect has made it difficult for those in charge of building budgets—either private or public—to justify expenditures in the short term, especially when money is tight. "Because the benefits of prevention often accrue decades later—long after someone has switched employers or health plans—private plans will skimp on prevention coverage," Goldman wrote in an op-ed in The New York Times last June.

The government need not simply step into the prevention arena out of beneficence, he noted. "Medicare could save itself money, for example, by paying for anti-hypertensive medication before people turn 65," he wrote.