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In a fiscal cliff debate being dominated by the biggest government programs in existence (Social Security, Medicare and Medicaid come to mind), the little guys are fighting for a seat at the table. Among them are public health advocates, who have already endured substantial cuts in recent years and warn that more could be catastrophic to the nation’s well-being.

They argue that federal funding for local public health efforts has already been slashed by $2.5 billion, an 8 percent cut, over the last two fiscal years. They repeat the sobering statistic -- a staple among public health advocates -- that 34,000 local health department jobs have been eliminated over that period. So lobbying groups like the National Association of City and County Health Officials (NACCHO) have been meeting constantly with Congress members since the election, pleading to spare already lean government entities from any further cuts.

“We're at the bottom of the food chain. The federal government gets its money, take its cuts, then it goes to the states, and they take their cuts. Then it finally gets to the local level, and there’s not much left,” says Laura Hanen, chief of government and public affairs at NACCHO. “We’ve already been on the chopping block, and we know we will continue to be.”

Unfortunately, there aren’t necessarily any great options for public health. If President Obama and House Republicans can’t reach a deal, the sequestration cuts that were part of the 2011 Budget Control Act will take effect. That means a 20 percent reduction for federal public health funding by 2021.

But a new deal could potentially be worse. House Republicans have demanded that the Affordable Care Act (which includes the Prevention and Public Health Fund, nearly $1 billion in new annual funding that public health circles call essential) be on the table. Though Obama is unlikely to gut his signature legislative achievement, his fiscal 2013 budget already proposed reducing the Prevention Fund by $4 billion over the next 10 years, a move that was decried at the time by NACCHO and its allies. In the context of hundreds of billions of dollars in Medicare, Medicaid and Social Security spending that the administration seems determined to protect, taking the relatively small hit to the Prevention Fund might be acceptable for the White House.

“We do expect another shave,” Hanen says. “We don't expect to get out of this without some pain, but I think a victory would be not very significant pain.”

So how do Hanen and company make their case while the national conversation (at least in the media) rages around the much more high-profile entitlement programs? At times, it means being in the awkward position of using recent tragedies -- the fungal meningitis outbreak and Hurricane Sandy being the foremost examples this time around -- as part of a lobbying pitch. During this fall’s meningitis outbreak, NACCHO’s Paul Etkind told Governing that, if another public health emergency struck while the system was already spread so thin, “we would see… just how tenuous the safety net really is.”

That’s part of the message that NACCHO has laid out in meetings with Congress members and their staffs in recent weeks. And it’s been the lawmakers from states affected by those tragedies -- New Jersey, Tennessee and Massachusetts among them -- who have been some of the most receptive to that argument.

“It strikes home to members who have recently experienced an emergency. Unfortunately, it takes those types of situations to bring it back to the forefront,” Hanen says. “People have very short-term memories around here.”

Public health advocates have found a few champions on Capitol Hill since the fiscal cliff talks began in earnest this month. Five Democratic Senators (Tom Harkin, Richard Durbin, Al Franken, Tom Udall and Richard Blumenthal) have circulated a “Dear Colleague” letter, urging their fellow Senators to spare the ACA’s Prevention Fund from any new spending cuts. They portray the fund as a deficit reduction tool in its own right, arguing that putting $10 per person per year into public health programs supported by the fund could save the country more than $16 billion in five years.

“If we’re serious about improving the health of the nation… we must control health care costs and promote a healthy, productive populace,” they wrote. “The best way to do that is to emphasize prevention.”

Over in the House, the California delegation (led by Democrats Doris Matsui, Lois Capps and Lucille Roybal-Allard) is collecting signatures for a similarly-worded letter to send to Obama as he takes the lead in negotiating with House Speaker John Boehner. They point to programs already supported by the Prevention Fund (smoking cessation in San Francisco and workplace wellness in San Diego, to name a few) as evidence of its potential impact.

“Our nation faces difficult fiscal decisions in the coming months,” the California Congressional delegation said in the letter. “However, prevention is the key to lowering health care costs and creating a long-term path to a healthier and economically sound in California and across America.”

But the prospects of a deal that saves the Prevention Fund and public health programs in general appear uncertain at best. As the Washington Post reported Friday, Boehner told reporters that negotiations had reached a “stalemate,” a little over a month before the various policies that make up the so-called fiscal cliff -- automatic tax increases and spending cuts that some speculate could reverse the already tepid economic recovery -- start to take effect.