As Congress struggles to decide how America should take care of its sick, another controversy is simmering over whether the healthcare legislation should include billions of dollars aimed at keeping people well.
A draft Senate bill would provide up to $10 billion annually for a "prevention and public health investment fund" -- a portion of which could be used for infrastructure projects, such as bike paths and farmers markets meant to curb chronic and costly conditions like obesity.
But though some lawmakers believe these initiatives could trim American waistlines and costs in the long run, others consider them pork-barrel spending.
One critic, Sen. Michael B. Enzi of Wyoming -- an accountant who is the top Republican on the Health, Education, Labor and Pension Committee -- called the provisions "wasteful spending" during a time of record deficits.
The bill will "pave sidewalks, build jungle gyms and open grocery stores," Enzi said, "but it won't bring down healthcare costs or make quality coverage more affordable."
But advocates say preventive efforts will bring down costs.
"We know these programs work," said Rich Hamburg, director of government relations for the Trust for America's Health, a nonpartisan organization that works to make disease prevention a national priority.
"In and of itself, prevention makes sense."
Trust for America's Health joined more than 300 organizations in urging lawmakers to include public health and prevention funds in the bill.
The group also led a 2008 report suggesting that an investment of $10 per person per year in "proven community-based programs" -- such as providing fresh produce through farmers markets -- could save America more than $16 billion in annual healthcare costs within five years.
Hamburg acknowledged Republican objections: "Their talking points are: 'Hey, this is going to build jungle gyms.' "
But he added: "Frankly, building healthy parks and making them easier to access is a good thing."
Hamburg said public health has been "chronically underfunded" for years and that the wellness and prevention provisions would help to reduce chronic disease in the long term.
"How can you tell people to go exercise if there aren't sidewalks?" he said.
Some lawmakers, including Sen. Tom Harkin (D-Iowa) -- who drafted the prevention and public health section of the Senate bill -- and House Speaker Nancy Pelosi (D-San Francisco), criticized Congressional Budget Office analyses of the draft bill for not taking into account potential savings from prevention and wellness measures.
The CBO concluded that healthcare costs would probably keep rising if the draft bill passed.
But the CBO says that its 10-year window of cost estimates takes into account only evidence of significant, measurable savings.
And although the proposed law authorizes prevention measures, additional legislation would be required to fund and implement them.
Senate Health Committee member Tom Coburn (R-Okla.), who is a physician, also opposed the wellness provisions and offered an amendment that would have prohibited funds from being used on "wasteful construction projects," such as farmers markets.
Rep. Tim Murphy (R-Pa.), a psychologist and co-chairman of both the Mental Health Caucus and the GOP Doctors Caucus, stresses the importance of preventive measures, personal responsibility and promoting healthy living -- particularly through lower health insurance rates for healthful behaviors.
"Shouldn't there be more credit given if someone's a nonsmoker?" he said.
But Murphy thinks infrastructure projects like bike trails probably belong in a transportation bill.
The healthcare legislation, he believes, must address how healthcare is delivered by doctors and hospitals.
In a House draft of the bill, up to $8.8 billion annually would be set aside for a public health investment fund, with up to $1.6 billion for community grants that could include infrastructure projects.
Negotiations over healthcare legislation coincide with a heightened focus on obesity.
Last week, the Centers for Disease Control and Prevention released a report indicating that the direct medical costs of obesity total about $147 billion annually.
That exceeds annual spending on cancer by more than $50 billion.
About half of these estimated costs are currently paid by Medicare and Medicaid.
But a concurrent CDC report also laid out "strategies" for combating obesity, many of which strikingly resemble drafted legislation: increasing the availability of healthful foods, and creating communities that support physical activity.
During last week's inaugural obesity conference held by the CDC, Health and Human Services Secretary Kathleen Sebelius had harsh words for the "infamous" CBO and what she called its "skeptical" stance toward prevention and wellness efforts.
"I happen to believe they're wrong, and in this case dead wrong," she said.
"Because Americans are starting to recognize that we're killing ourselves, and more importantly we're killing our children, and we need to change our ways."