Sens. Barbara Mikulski (D-Md.), center, and Tom Harkin (D-Iowa) have been key supporters of the health reform law’s Prevention and Public Health Fund. (Carolyn Kaster/AP)

The mix of pay-fors is being sorted out and looks like it could include having federal employees pay more into their pensions, as well as cuts to an assortment of health-care provisions. But one program that could take the biggest hit is the health reform law’s Prevention and Public Health Fund. The Hill’s Julian Pecquet reports that legislators are looking to use $5 billion from the fund to shore up Medicare provider payments. That would cut away a full third of the Prevention Fund’s current budget.

This isn’t the first time the Prevention Fund has landed on the chopping block. President Obama has repeatedly endorsed cutting its budget as a means to reduce the deficit, while Republicans have voted to repeal the fund altogether. This is a bit ironic, given how much both parties talk about the need to invest in prevention to bring down the cost of health care. What gives?

The University of Richmond’s Rick Mayes and Thomas Oliver of the University of Wisconsin recently shed some light on why, despite getting a lot of lip service, prevention tends to be a political lightweight. In last month’s Journal of Health Politics, Policy and Law, they noted four reasons why efforts to prevent or reduce costly diseases run up against a host of political obstacles. A lot of it has to do with the fact that when prevention works best, you don’t see it. If a disease is prevented, there’s not much concrete for a legislator to point to. This is what Mayes describes as the “Prevention Paradox:” “If public health measures are effective, the problems they are aimed at are often solved or never even materialize, thereby making them virtually invisible.

“Few individuals have personal interactions with or know what epidemiologists, health program coordinators, virology trainers, and outreach specialists do,” he continues. “When individuals are spared from a disease because the air in their office building is clean, it is not immediately clear whom to thank or if thanks are even necessary. As a consequence, public health professionals, programs, and policies are largely invisible to the public and taken for granted.”

Another big obstacle, he writes, has to do with timing: Prevention tends to show its effect in statistics, over long periods of time, as smoking rates might go down or vaccination rates go up. Those delays may be inherent to how public health works, but they also make it hard for a legislator running for office a year or two from now to campaign on.

This has been a persistent worry of the Prevention Fund’s supporters: If it doesn’t show concrete results fast, it won’t survive. “We’ve got to get this going,” Sen. Barbara Mikulski (D-Md.) said of the Prevention Fund at a hearing late last year. “There’s doubt; people think this is a slush fund. The president himself wanted to cut it. We’ve got this window, we’ve got to show movement and momentum ... otherwise we’re going to lose the opportunity.”

In this week’s doc-fix deal, some of Mikulski’s predictions look to be coming true.