< Back to Current Version

Appropriations and Fund Transfers in the Affordable Care Act (ACA)

Changes from February 10, 2011 to January 15, 2013

This page shows textual changes in the document between the two versions indicated in the dates above. Textual matter removed in the later version is indicated with red strikethrough and textual matter added in the later version is indicated with blue.

Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act (PPACAACA) C. Stephen Redhead Specialist in Health Policy February 10, 2011January 15, 2013 Congressional Research Service 7-5700 www.crs.gov R41301 CRS Report for Congress Prepared for Members and Committees of Congress Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act Summary On March 23, 2010, President Obama signed into law a comprehensive health care reform bill, the Patient Protection and Affordable Care Act (PPACA; P.L. 111-148). The following week, on March 30, 2010, the President signed the Health Care and Education Reconciliation Act of 2010 (HCERA; P.L. 111-152), which amended various health care and revenue provisions in PPACA. Among its many provisions, PPACA, as amended, restructures Among its many provisions, the Patient Protection and Affordable Care Act (ACA) restructures the private health insurance market, sets minimum standards for health coverage, creates a mandate forand, beginning in 2014, mandates that most U.S. residents to obtain health insurance, and provides for the establishment by 2014 of insurance exchanges through which certain coverage or pay a penalty. The law provides for the establishment by 2014 of state-based health insurance exchanges for the purchase of private health insurance. Qualifying individuals and families will be able to receive federal subsidies to reduce the cost of purchasing that coverage. The new law coverage through the exchanges. ACA also expands eligibility for Medicaid; amends the Medicare program in ways that are intended to reduce the growth in Medicare spending that had been projected under preexisting law; imposes an excise tax on insurance plans found to have high premiums reduce the growth in spending; and makes other changes to the tax code, Medicare, Medicaid, and numerous other federal programs. In some instances, PPACA mandates appropriations or requires the Secretary of Health and Human Services to transfer from the Medicare Part A and Part B trust funds many other federal programs. In addition, ACA appropriates billions of dollars to support new or existing grant programs and other activities. This report summarizes those mandated appropriations and fund transfers. They include funding other activities. These mandatory appropriations include funds for a temporary insurance program program for individuals who have been uninsured for several months and have a preexisting condition, as well as funding for states to plan and establish exchanges. PPACAACA also provides funding for various Medicare and Medicaid demonstration programs, for the creation of a Center for Medicare and Medicaid Innovation to test and implement innovative payment and service delivery models, and for an independent board to provide Congress with proposals for reducing Medicare cost growth and improving quality of care for Medicare beneficiaries. Among other provisions, the new health reform law appropriatesACA provides funding for health workforce and maternal and child health programs, and establishes three multi-billion dollar funds. The first fund will provide a total of $11 billion over five years in supplementary funding for community health centers and the National Health Service Corps. (A separate appropriation provides $1.5 billion for health center construction and renovation.) The second fund will support comparative effectiveness research through FY2019 with a mixture of mix of appropriations and fund transfers. The third fund, which is funded in perpetuity, is transfers from the Medicare trust funds. The third fund, for which ACA provides a permanent annual appropriation, is intended to support prevention, wellness, and other public public health-related programs and activities authorized under the Public Health Service Act (PHSA). This report will be updated periodically with information on recent PPACA funding announcements. In addition to the mandated appropriations and fund transfers discussed herein, PPACA authorizes new funding for numerous existing discretionary grant and other programs and activities, primarily ones authorized under the PHSA. The law also creates a number of new discretionary grant programs and activities and provides for each an authorization of appropriations. Funding for all of these discretionary programs and activities is subject to action by congressional appropriators. A companion product, CRS Report R41390, Discretionary Funding in the Patient Protection and Affordable Care Act (PPACA), coordinated by C. Stephen Redhead, summarizes all the provisions in PPACA for which appropriations are authorizedGenerally, the FY2013 mandatory appropriations in ACA would be fully sequestrable at the rate applicable to nonexempt nondefense mandatory spending, under a sequestration order triggered by the Budget Control Act. Lawmakers opposed to ACA introduced numerous bills in the 112th Congress, several of which saw legislative action. They included measures to repeal ACA and replace it with new law; repeal or amend specific ACA provisions; eliminate certain mandatory appropriations and rescind all unobligated funds; and block or otherwise delay ACA implementation. Similar legislation may be introduced and debated during the 113th Congress. In addition to the mandatory appropriations discussed in this report, ACA authorizes new funding for numerous existing discretionary grant and other programs, primarily ones authorized under the PHSA. The law also creates a number of new discretionary grant programs and activities and provides for each an authorization of appropriations. Funding for all these discretionary programs and activities is subject to action by congressional appropriators. A companion product, CRS Report R41390, Discretionary Spending in the Patient Protection and Affordable Care Act (ACA), summarizes all the provisions in ACA that include an authorization of appropriations. Congressional Research Service Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act Contents Introduction ...................................................................................................................................... 1 Mandatory1 PPACA Mandated Appropriations and Fund Transfers in ACA ...........................................................1 PPACA Discretionary Funding ....... 2 Discretionary Spending in ACA ....................................................................................................3 CRS Products.. 5 Potential Impact of Spending Cuts Under the Budget Control Act ................................................. 5 BCA Background.........................................................................3 Tables Table 1. Description of Appropriations and Fund Transfers in the Health Reform Law.................4 Table 2. Appropriations and Fund Transfers in the Health Reform Law, FY2010-FY2019.......... 16 Contacts Author Contact Information .............................................. 6 FY2013 Nondefense Direct Spending Reductions .................................................................... 7 Tables Table 1. Summary of Mandatory Appropriations and Medicare Trust Fund Transfers in the Affordable Care Act ................................................................................................................ 9 Table 2. ACA Appropriations and Fund Transfers by Fiscal Year ................................................. 19 Appendixes Appendix A. Acronyms Used in the Report................................................................................... 24 Appendix B. ACA-Related Authorizing Legislation in the 112th Congress................................... 25 Appendix C. ACA Provisions in Appropriations Bills (FY2011-FY2013).................................... 28 Contacts Author Contact Information......................................................................................................... 21 Acknowledgments .. 31 Acknowledgments ........................................................................................................................ 21. 31 Congressional Research Service Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act Introduction On March 23, 2010, President Obama signed into law a comprehensive health care reform bill, the Patient Protection and Affordable Care Act (PPACA; P.L. 111-148). The following week, on March 30, 2010, the President signed the Health Care and Education Reconciliation Act of 2010 (HCERA; P.L. 111-152), which amended various health care and revenue provisions in PPACA. 1 Among its many provisions, PPACA, as amended, restructures the private health insurance market, sets minimum standards for health coverage, creates a mandate for most U.S. residents to obtain health insurance, and provides for the establishment by 2014 of insurance exchanges through which certain individuals and families will be able to receive federal subsidies to reduce the cost of purchasing that coverage. The new law expands eligibility for Medicaid; amends the Medicare program in ways that are intended to reduce the growth in Medicare spending that had been projected under preexisting law; imposes an excise tax on insurance plans found to have high premiums; and makes other changes to the tax code, Medicare, Medicaid, and numerous other federal programs. PPACA Mandated Appropriations and Fund Transfers In some instances, PPACA, as amended, mandates appropriations or requires the Secretary of Health and Human Services (HHS) to transfer from the Medicare Part A and Part B trust funds billions of dollars to support new or existing grant programs and other activities. The new law includes funding for a temporary insurance program for individuals who have been uninsured for several months and have a preexisting condition, as well as funding for states to plan and establish exchanges. PPACA also provides funding for various Medicare and Medicaid demonstration programs, for the creation of a Center for Medicare and Medicaid Innovation to test and implement innovative payment and service delivery models, and for an independent board to provide Congress with proposals for reducing Medicare cost growth and improving quality of care for Medicare beneficiaries. Among other provisions, PPACA appropriates funding for health workforce and maternal and child health programs, and establishes three multi-billion dollar funds. The first fund will provide a total of $11 billion over five years in supplementary funding for community health centers and the National Health Service Corps. (A separate appropriation provides $1.5 billion for health center construction and renovation.) The second fund will support comparative effectiveness research through FY2019 with a mixture of appropriations and fund transfers. The third fund, which is funded in perpetuity, is to support prevention, wellness, and other public health-related programs and activities authorized under the Public Health Service Act (PHSA). Table 1 summarizes all such appropriations and fund transfers, grouped under the following headings: (1) Private Health Insurance; (2) Medicaid and the Children’s Health Insurance Program (CHIP); (3) Medicare; (4) Fraud and Abuse; (5) Health Centers and the National Health Service Corps (NHSC); (6) Health Workforce; (7) Community-Based Prevention and Wellness; 1 A consolidated version of PPACA, incorporating the changes made by the health-related provisions in HCERA, is available at http://statutes.legcoun.house.gov/PDF/ppacacon.PDF. Congressional Research Service 1 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act (8) Maternal and Child Health; (9) Long-Term Care; (10) Comparative Effectiveness Research; (11) Biomedical Research; and (12) PPACA Implementation. Each table entry includes the following information: (1) the PPACA section number; (2) an indication of whether the provision modifies the Public Health Service Act or another law either by amending an existing section or by adding a new one, or whether the provision creates new stand-alone statutory authority; (3) a brief description of the program or activity (with the name of the administering HHS agency, if known); and (4) details of the appropriation or transfer of funds. In most cases, the language specifies funding levels or transfer amounts for one or more fiscal years. However, three provisions appropriate or transfer “such sums as may be necessary” (SSAN) to carry out a program. Two other provisions (i.e., Secs. 1311 and 6201) specify that it is for the HHS Secretary to determine, within certain parameters, the amount necessary for the program. Table 1 entries also include information on, and web addresses for, official HHS announcements on PPACA funding availability and/or grant awards.2 Table 2 shows the amounts appropriated or transferred in each provision by fiscal year, over the 10-year period FY2010 through FY2019. The information is organized and grouped under the same headings used in Table 1. Unless otherwise stated, references to the Secretary in both tables refer to the HHS Secretary. The following laws and federal agencies are referred to in the tables by their acronym: • Administration on Aging (AoA) • Administration for Children and Families (ACF) • Agency for Healthcare Research and Quality (AHRQ) • Centers for Disease Control and Prevention (CDC) • Centers for Medicare & Medicaid Services (CMS) • Deficit Reduction Act of 2005 (DRA; P.L. 109-171) • Health Resources and Services Administration (HRSA) • HHS Office of the Secretary (OS) • Internal Revenue Code (IRC) • Internal Revenue Service (IRS) • Medicare Improvements for Patients and Providers Act of 2008 (MIPPA; P.L. 110-275) • Older Americans Act (OAA) • Public Health Service Act (PHSA) 2 The information in the table on PPACA funding activities is largely drawn from HHS news releases (http://www.hhs.gov/news/). It is not intended to be a complete summary of all such activities. Readers are encouraged to visit other official federal websites that are tracking and providing information on PPACA implementation (e.g., http://www.healthcare.gov; http://www.hhs.gov/cciio/). Congressional Research Service 2 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act • Social Security Act (SSA) PPACA Discretionary Funding In addition to the mandated appropriations and fund transfers discussed in this report, PPACA, as amended, authorizes new funding for numerous existing discretionary grant and other programs and activities, primarily ones authorized under the PHSA. While the authorization of appropriations for most of these programs expired prior to PPACA’s enactment, many of them continued to receive an annual appropriation. PPACA also authorizes a number of new discretionary programs and activities and provides for each an authorization of appropriations. Funding for all of these discretionary programs and activities is subject to action by congressional appropriators. However, it is often the case that new programs and activities face more of a challenge in securing funding than do existing ones with an established appropriations history. A companion product, CRS Report R41390, Discretionary Funding in the Patient Protection and Affordable Care Act (PPACA), summarizes all the provisions in PPACA for which appropriations are authorized. CRS Products More information on the PPACA provisions summarized in the tables below may be found in the following CRS products: • CRS Report R40942, Private Health Insurance Provisions in the Patient Protection and Affordable Care Act (PPACA) • CRS Report R41210, Medicaid and the State Children’s Health Insurance Program (CHIP) Provisions in PPACA: Summary and Timeline • CRS Report R41196, Medicare Provisions in the Patient Protection and Affordable Care Act (PPACA): Summary and Timeline • CRS Report R41278, Public Health, Workforce, Quality, and Related Provisions in PPACA: Summary and Timeline Congressional Research Service 3 Table 1. Description of Appropriations and Fund Transfers in the Health Reform Law Patient Protection and Affordable Care Act (PPACA; P.L. 111-148, as amended by P.L. 111-152) PPACA Section New/Existing Authority Program Description Appropriation/Transfer Health insurance consumer information. Requires the Secretary to award grants to states to enable them (or the exchanges operating in such states) to establish, expand, or provide support for offices of health insurance consumer assistance, or health insurance ombudsman programs. These independent entities will assist consumers with filing complaints and appeals, educate consumers on their rights and responsibilities, and collect, track, and quantify consumer problems and inquiries. [OS] Appropriates $30 million for the first fiscal year of the program, to remain available without fiscal year limitation. Note: the section also authorizes to be appropriated SSAN for each fiscal year thereafter. Review of health insurance premium rates. Requires the Secretary, in conjunction with the states, to establish a process for the annual review of unreasonable increases in health insurance premiums beginning in the 2010 plan year. Health insurance issuers must submit a justification for a premium increase judged to be unreasonable prior to its implementation. Instructs the Secretary to establish a formula for awarding grants to states during the five-year period FY2010 through FY2014 for carrying out the premium review. No state shall receive less than $1 million or more than $5 million in a grant year. State grantees are required to provide the Secretary with information about trends in premium increases, including recommendations as to whether particular issuers should be excluded from participation in the exchange due to a pattern of excessive or unjustified premium increases. [OS] Appropriates $250 million for the grant program. Funds remaining unobligated at the end of FY2014 shall remain available for grants to states for planning and implementing PPACA’s individual and group market reforms. High-risk pools for individuals with preexisting conditions. Requires the Secretary, within 90 days of enactment, to establish a temporary high-risk pool program to provide health insurance coverage for eligible individuals who have been uninsured for six months and have a preexisting condition. The program, which is known as the Pre-Existing Condition Insurance Plan (PCIP), terminates on Jan. 1, 2014. PCIP permits premium rates to vary on the basis of age by a factor of up to 4:1 and places limits on out-of-pocket costs. [OS] Appropriates $5 billion, to remain available without fiscal year limitation, to pay claims against (and administrative costs of) the high-risk pool that are in excess of premiums collected from enrollees. Private Health Insurance 1002 New PHSA Sec. 2793 1003 New PHSA Sec. 2794 1101 New authority CRS-4 [On Oct. 19, 2010, HHS announced Consumer Assistance Program (CAP) grant awards totaling almost $30 million to 35 states, 4 territories, and the District of Columbia (DC). See http://www.hhs.gov/news/press/ 2010pres/10/20101019a.html.] [On Aug. 16, 2010, HHS announced an initial round of grant awards totaling $46 million to 45 states and DC. See http://www.hhs.gov/news/ press/2010pres/08/20100816a.html. Further, on Dec. 23, 2010, HHS published a proposed rule that would establish a rate review program to ensure that all rate increases that meet or exceed a threshold are reviewed by a state or HHS to determine whether the increases are unreasonable. See http://www.hhs.gov/news/press/2010pres/12/ 20101221a.html.] [For a fact sheet on the PCIP program including a list of the potential allocation of funds, by state, see http://www.hhs.gov/ociio/initiative/ hi_risk_pool_facts.html. For more details about the PCIP program in each state, see http://www.healthcare.gov/news/factsheets/preexisting_condition_insurance_enrollment.html.] PPACA Section 1102 New/Existing Authority New authority 1311 New authority Program Description Appropriation/Transfer Reinsurance for early retirees. Requires the Secretary, within 90 days of enactment, to establish a temporary reinsurance program, ending on Jan. 1, 2014, to provide reimbursement to participating employer-based plans for part of the cost of providing health benefits to early retirees age 55-64 and their families. The program reimburses participating plans for 80% of the costs of benefits provided per enrollee in excess of $15,000 and below $90,000. Funds must be used to lower costs for the plan; for example, the funds could be used to reduce premium costs or lower outof-pocket costs for beneficiaries. [OS] Appropriates $5 billion, to remain available without fiscal year limitation, to carry out the reinsurance program. Health insurance exchanges. Requires the Secretary, within one year of enactment, to award grants to states to plan and establish exchanges. By Jan. 1, 2014, each state must have an exchange to facilitate access to insurers’ qualified health plans. The grants can be renewed to states making progress in establishing an exchange, implementing PPACA’s private health insurance market reforms, and meeting other benchmarks. However, no grant may be awarded after Jan. 1, 2015. Exchanges will have to be self-sustaining by then, using assessments on insurers or some other way to generate funds to support their operations. [OS] Appropriates amounts necessary for the Secretary to award state grants. For each fiscal year, the Secretary must determine the total amount that will be made available to each state. [For more information on the early retiree reinsurance program, including recent news and announcements, see http://www.errp.gov/.] [On Sept. 30, 2010, HHS announced grant awards totaling $49 million to 48 states and DC for planning health insurance exchanges. See http://www.healthcare.gov/news/factsheets/esthealthinsurexch.html. On Jan. 20, 2011, HHS announced the availability of health insurance exchange establishment grants and encouraged states to apply for funding. See http://www.hhs.gov/news/press/2011pres/01/20110120b.html.] 1322 New authority Health insurance cooperatives. Requires the Secretary to establish the Consumer Operated and Oriented Plan (CO-OP) program to provide funding until July 1, 2013, for the creation of nonprofit member-run health insurance issuers that offer qualified health plans in the individual and small group markets. Funds are to be provided as loans for start-up costs and as grants for meeting solvency requirements. Loans must be repaid within 5 years; grants must be repaid within 15 years. Prohibits health insurance issuers that existed on July 16, 2009, or governmental organizations from participating in the CO-OP program. [OS] Appropriates $6 billion to carry out the CO-OP program. 1323 New authority Funding for territories. Provides funds for U.S. territories that elect to establish a health insurance exchange. Funds must be used to provide premium and cost-sharing assistance to territory residents who obtain health insurance coverage through the exchange. Appropriates $1 billion, to be available during the period 2014 through 2019. Of that total amount, $925 million is for Puerto Rico, and the remaining $75 million is for the other U.S. territories in amounts as specified by the Secretary. CRS-5 PPACA Section New/Existing Authority Program Description Appropriation/Transfer Medicaid and Children’s Health Insurance Program (CHIP) 2701 New SSA Sec. 1139B 2707 New authority 2801 Amends SSA Sec. 1900 Medicaid adult health quality measures. Requires the Secretary to develop and, not later than Jan. 1, 2012, publish an initial core set of quality measures for Medicaid-eligible adults. Not later than January 1, 2013, requires the Secretary to develop a standardized format for states to report information about the quality of Medicaid care for adults based on those measures. The Secretary and the states must report on the development of and improvements to the quality measurement program on a regular basis. [CMS] Appropriates $60 million for each of FY2010 through FY2014, to remain available until expended. (Total amount = $300 million.) Medicaid emergency psychiatric demonstration program. Directs the Secretary to establish a three-year Medicaid demonstration in which eligible states are required to reimburse certain institutions for mental disease (IMDs) for services provided to Medicaid beneficiaries aged 21 through 64 who are in need of medical assistance to stabilize an emergency psychiatric condition. [CMS] Appropriates $75 million for FY2011, to remain available for obligation through Dec. 31, 2015. Medicaid and CHIP Payment and Access Commission (MACPAC). Clarifies and expands MACPAC’s duties; for example, to include a review and assessment of payment policies under Medicaid and CHIP and how factors affecting expenditures and payment methodologies enable beneficiaries to obtain services, affect provider supply, and affect providers that serve a disproportionate share of low-income and other vulnerable populations. Additional duties include reviewing and assessing policies related to eligibility, enrollment and retention, benefits and coverage, quality of care, and interactions between Medicaid and Medicare and how those interactions affect access to services, payments, and dual eligibles. MACPAC is also required to report to Congress on any Medicaid and CHIP regulations that affect access, quality, and efficiency of health care. [CMS] Appropriates $9 million, and transfers from CHIP funding an additional $2 million for FY2010 for MACPAC activities. Note: the section also authorizes to be appropriated SSAN for each fiscal year thereafter. Funds are to remain available until expended. (Total amount = $11 million.) [On Dec. 30, 2010, HHS published a notice with comment period identifying an initial core set of health quality measures recommended for Medicaid-eligible adults. See http://edocket.access.gpo.gov/2010/pdf/201032978.pdf.] [For more information on the demonstration, see http://www.samhsa.gov/ healthreform/docs/Medicaid_Emergency_Psychiatric_Demo_508.pdf.] [For information on MACPAC, see http://www.macpac.gov/.] 4108 New authority Medicaid prevention and wellness incentives. Requires the Secretary to award state grants to provide incentives for Medicaid beneficiaries to participate in evidence-based healthy lifestyle programs to prevent or help manage chronic disease. [CMS] Appropriates $100 million for the five-year period beginning Jan. 1, 2011, to remain available until expended. 4306 Amends SSA Sec. 1139A(e) CHIP childhood obesity demonstration program. Appropriates funding for a program authorized by the Children’s Health Insurance Program Reauthorization Act (CHIPRA; P.L. 111-3), which requires the Secretary to conduct a demonstration project to develop a model for reducing childhood obesity. [CDC] Appropriates $25 million for the period FY2010 through FY2014. CRS-6 PPACA Section 10203(d) New/Existing Authority Amends SSA Secs. 2104 & 2113 Program Description Appropriation/Transfer CHIP annual appropriations, and outreach and enrollment grants. Appropriates funding for the CHIP program for FY2014 and FY2015 (the program previously had been funded through FY2013). Also, extends the time period for CHIP outreach and enrollment grants through FY2015 and increases the existing appropriation for such grants from $100 million to $140 million. Appropriates $19.147 billion for FY2014, and a total of $21.061 billion for FY2015 for the CHIP program. Appropriates an additional $40 million for the CHIP outreach and enrollment grants. [For information on the CHIP outreach and enrollment grants, see http://www.cms.gov/CHIPRA/11_outreachenrollmentgrants.asp.] Medicare 3014 Amends SSA Sec. 1890(b). New SSA Sec. 1890A Medicare quality and efficiency measures. Expands the duties of the consensus-based entity under contract with CMS pursuant to SSA Sec. 1890 (currently the National Quality Forum). Requires the entity to convene multi-stakeholder groups to provide input on the national priorities for health care quality improvement (developed under PPACA). In addition, the multi-stakeholder groups are required to provide input on the selection of quality measures for use in various specified Medicare payment systems for hospitals and other providers, as well as in other health care programs, and for use in reporting performance information to the public. Establishes a multi-step pre-rulemaking process and timeline for the adoption, dissemination, and review of measures by the Secretary. [CMS] Requires the Secretary to transfer from the Medicare Part A and Part B trust funds $20 million for each of FY2010 through FY2014, to remain available until expended.a (Total amount = $100 million.) 3021(a) New SSA Sec. 1115A Center for Medicare and Medicaid Innovation (CMI). Requires the Secretary, no later than January 1, 2011, to establish the CMI within the Centers for Medicare and Medicaid Services (CMS). The purpose of CMI is to test and evaluate innovative payment and service delivery models to reduce program expenditures under Medicare, Medicaid, and CHIP while preserving or enhancing the quality of care furnished under these programs. In selecting the models, the Secretary is also required to give preference to those that improve the coordination, quality, and efficiency of health care services. [CMS] Appropriates (1) $5 million for FY2010 for the selection, testing, and evaluation of new payment and service delivery models; and (2) $10 billion for the period FY2011 through FY2019, plus $10 billion for each subsequent 10-fiscal year period, to continue such activities and for the expansion and nationwide implementation of successful models.b Amounts are to remain available until expended. Medicare independence at home demonstration program. Requires the Secretary to conduct a three-year Medicare demonstration program, beginning no later than Jan. 1, 2012, to test a payment incentive and service delivery model aimed at reducing expenditures and improving health outcomes that uses physician- and nurse practitioner-directed primary care teams to provide home-based services to chronically ill patients. The Secretary must submit a plan, no later than January 1, 2016, for expanding the program if it is determined that such expansion would improve the quality of care and reduce spending. [CMS] Requires the Secretary to transfer from the Medicare Part A and Part B trust funds $5 million for each of FY2010 through FY2015 for administering and carrying out the demonstration, to remain available until expended.a (Total amount = $30 million.) 3024 New SSA Sec. 1866E CRS-7 [For information on CMI, see http://innovations.cms.gov/.] [For a fact sheet on the independence at home demonstration, see http://www.cms.gov/DemoProjectsEvalRpts/downloads/ IAH_FactSheet.pdf.] PPACA Section New/Existing Authority Program Description Appropriation/Transfer 3026 New authority Community-based care transitions program. Requires the Secretary to establish a five-year program, beginning Jan. 1, 2011, to provide funding to eligible hospitals and community-based organizations that provide evidence-based transition services to Medicare beneficiaries with multiple chronic conditions who are at high risk for hospital readmission. [CMS] Requires the Secretary to transfer from the Medicare Part A and Part B trust funds $500 million for the period FY2011 through FY2015, to remain available until expended.a 3027(b) Amends DRA Sec. 5007 Medicare gainsharing demonstration program. Under DRA Sec. 5007, CMS is supporting two gainsharing projects to test and evaluate arrangements between hospitals and physicians that are intended to improve the quality and efficiency of care provided to beneficiaries. The demonstration allows hospitals to provide gainsharing payments to physicians that represent a share of the savings incurred as a result of collaborative efforts to improve overall quality and efficiency. [CMS] Appropriates $1.6 million for FY2010, to remain available through FY2014 or until expended, for carrying out the demonstration. 3113 New authority Diagnostic laboratory test demonstration program. Requires the Secretary to conduct a 2-year demonstration program, with a subsequent report to Congress, to test the impact of direct payments for certain complex laboratory tests on Medicare costs and quality of care. [CMS] Requires the Secretary to transfer from the Medicare Part B trust fund $5 million, to remain available until expended, for carrying out the demonstration program and preparing the subsequent report. 3306 Amends MIPPA Sec. 119 Outreach and assistance for Medicare low-income programs. Provides additional funding for beneficiary outreach and education activities for Medicare low-income programs through the following entities: (1) State Health Insurance Counseling and Assistance Programs (SHIPs); (2) Area Agencies on Aging (AAAs); (3) Aging and Disability Resource Centers (ADRCs); and (4) the National Center for Benefits and Outreach Enrollment (NCBOE). [AoA, CMS] Appropriates a total of $45 million for the period FY2010 through FY2012, to remain available until expended, as follows: (1) $15 million for SHIPs; (2) $15 million for AAAs; (3) $10 million for ADRCs; and (4) $5 million for the NCBOE. CRS-8 [On Sept. 27, 2010, HHS announced grant awards totaling $45 million to 50 states, the territories, and 125 tribal organizations for Medicare beneficiary outreach and assistance. Of this amount, $5 million was awarded to NCBOE for technical assistance. See http://www.hhs.gov/ news/press/2010pres/09/20100927a.html.] PPACA Section New/Existing Authority Program Description Appropriation/Transfer 3403 New SSA Sec. 1899A Independent Payment Advisory Board. Creates an independent, 15member Payment Advisory Board tasked with presenting Congress with comprehensive proposals to reduce excess cost growth and improve quality of care for Medicare beneficiaries. In years when Medicare costs are projected to exceed a target growth rate, the board’s proposals will take effect unless Congress passes an alternative measure that achieves the same level of savings. Congress would be allowed to consider an alternative provision on a fast-track basis. The board would be prohibited from making proposals that ration care, raise taxes, or increase Part B premiums, or change Medicare benefit, eligibility, or cost-sharing standards. Requires the board to make biannual recommendations to the President, Congress, and private entities on actions they can take to improve quality and constrain the rate of cost growth in the private sector. Requires the board to make non-binding Medicare recommendations to Congress in years in which Medicare growth is below the targeted growth rate. Beginning in 2019, limits the board’s binding recommendations to Congress to every other year if the growth in overall health spending exceeds growth in Medicare spending; such recommendations would focus on slowing overall health spending while maintaining or enhancing beneficiary access to quality care under Medicare. Appropriates $15 million for FY2012 to support the board’s activities. For each subsequent fiscal year, appropriates the amount from the previous fiscal year adjusted for inflation. Sixty percent of the appropriation is to be derived by transfer from the Medicare Part A trust fund, and 40% is to be derived by transfer from the Medicare Part B trust fund. 4202(b) New authority Medicare prevention and wellness evaluation. Requires the Secretary to conduct an evaluation of community-based prevention and wellness programs and, based on the findings, develop a plan to promote healthy lifestyles and chronic disease self-management among Medicare beneficiaries. [CMS] Requires the Secretary to transfer $50 million from the Medicare Part A and Part B trust funds to fund the evaluation, to remain available until expended.a 4204(e) New authority Medicare vaccine coverage. Requires the GAO to study and report to Congress on the impact of Medicare Part D vaccine coverage on access to those vaccines among beneficiaries. Appropriates $1 million for FY2010 for the GAO study. 10323(a) New SSA Sec. 1881A Environmental health hazards. Extends Medicare coverage to certain individuals exposed to environmental health hazards. Requires the Secretary to establish a pilot program, with appropriate reimbursement methodologies, to provide comprehensive, coordinated, and cost-effective care to certain exposed individuals residing in emergency declaration areas. [CMS] Requires the Secretary to transfer SSAN from the Medicare Part A and Part B trust funds to carry out the pilot program.a CRS-9 PPACA Section 10323(b) New/Existing Authority New SSA Sec. 2009 Program Description Appropriation/Transfer Environmental health hazards. Requires the Secretary to award grants to state and local government agencies, health care facilities, and other entities to (1) provide screening for specified lung diseases and other environmental health conditions to at-risk individuals; and (2) disseminate public information about the availability of screening, the detection and treatment of environmental health conditions, and the availability of Medicare benefits to certain individuals diagnosed with such conditions, pursuant to new SSA Sec. 1881A (as added by PPACA Sec. 10323(a)). [CMS] Appropriates $23 million for the period FY2010 through FY2014, and $20 million for each five-fiscal year period thereafter, to carry out the screening and public information dissemination program. Funds are to remain available until expended. Health Care Fraud and Abuse Control (HCFAC) Account. Permanently applies an inflation adjustment to the annual appropriation (provided under SSA Sec. 1817(k)) for the HCFAC Account, which finances investigative and enforcement activities undertaken by the HHS Office of the Inspector General, the Department of Justice, and the Federal Bureau of Investigation, as well as Medicare Integrity Program activities undertaken by CMS contractors. In addition, provides supplemental funds through FY2020 for the HCFAC Account. [CMS] Appropriates from the Medicare Part A trust fund $10 million for each of FY2011 through FY2020; plus an additional $95 million for FY2011, $55 million for FY2012, $30 million for each of FY2013 and FY2014, and $20 million for each of FY2015 and FY2016. Funds are to remain available until expended. (Total amount = $350 million.) Fraud and Abuse 6402(i) & HCERA Sec. 1303(a) Amends SSA Sec. 1817(k) Health Centers and the National Health Service Corps 4101(a) 10503(b)(1) CRS-10 New authority New authority School-based health centers. Requires the Secretary to create a grant program for the establishment of school-based health centers. Funds may be used for facility construction, expansion, and equipment. [HRSA] Appropriates $50 million for each of FY2010 through FY2013, to remain available until expended. (Total amount = $200 million.) Community Health Center Fund (CHCF). Establishes a CHCF and appropriates to the fund a total of $11 billion over the five-year period FY2011 through FY2015. Requires the Secretary to transfer $9.5 billion from the CHCF to increase funding, over the FY2008 level, for community health center operations. The remaining $1.5 billion is discussed in the next table row. [HRSA] Transfers from the CHCF the following amounts for health center operations, to remain available until expended: FY2011 = $1 billion; FY2012 = $1.2 billion; FY2013 = $1.5 billion; FY2014 = $2.2 billion; and FY2015 = $3.6 billion. (Total amount = $9.5 billion.) [On Oct. 4, 2010, HHS announced the availability of $100 million for school-based health center construction and renovation. See http://www.hrsa.gov/about/news/pressreleases/ 101004schoolbasedhealthcenters.html.] [For HHS/HRSA announcements on the FY2011 health center funds, see (1) http://www.hhs.gov/news/press/2010pres/08/20100809a.html; (2) http://www.hhs.gov/news/press/2010pres/10/20101026a.html; (3) http://www.hhs.gov/news/press/2010pres/11/20101119b.html; and (4) http://www.hrsa.gov/about/news/pressreleases/ 110107healthcenterplanning.html.] PPACA Section 10503(b)(2) New/Existing Authority New authority Program Description National Health Service Corps (NHSC). Requires the Secretary to transfer from the CHCF a total of $1.5 billion to increase funding, over the FY2008 level, for NHSC operations, scholarships, and loan repayments. [HRSA] Appropriation/Transfer Transfers from the CHCF the following amounts for NHSC, to remain available until expended: FY2011 = $290 million; FY2012 = $295 million; FY2013 = $300 million; FY2014 = $305 million; and FY2015 = $310 million. (Total amount = $1.5 billion.) [On Nov. 22, 2010, HHS announced the availability of the FY2011 NHSC funds. See http://www.hhs.gov/news/press/2010pres/11/20101122b.html.] 10503(c) New authority Health center construction and renovation. Provides funding for health center construction and renovation. [HRSA] Appropriates $1.5 billion, to be available for the period FY2011 through FY2015, and to remain available until expended. [On Oct. 8, 2010, HHS announced awards totaling $727 million for CHC construction and renovation. See http://www.hhs.gov/news/press/ 2010pres/10/20101008c.html.] Health Workforce 5507(a) 5507(b) 5508(c) CRS-11 New SSA Sec. 2008 Amends SSA Sec. 501(c) New PHSA Sec. 340H Health workforce demonstration programs. Requires the Secretary to establish two demonstration projects. The first is to award health profession opportunity grants to states, Indian tribes, institutions of higher education, and local workforce investment boards to help low-income individuals obtain education and training in health care jobs that pay well and are in high demand; funds may be used to provide financial aid and other supportive services. The second is to provide states with grants to develop core training competencies and certification programs for personal and home care aides. [ACF, HRSA] Appropriates $85 million for each of FY2010 through FY2014, of which $5 million in each of FY2010 through FY2012 is to be used for the second project. (Total amount = $425 million.) Family-to-family health information centers. Renews funding for the family-to-family information centers, which assist families of children with disabilities or special health care needs and the professionals who serve them. [HRSA] Appropriates $5 million for each of FY2010 through FY2012, to remain available until expended. (Total amount = $15 million.) Teaching health centers. Requires the Secretary to make payments for direct and indirect graduate medical education (GME) costs to qualified teaching health centers (THCs) for the expansion of existing, or establishment of new approved medical residency training programs. [HRSA] Appropriates SSAN, not to exceed $230 million, for the period FY2011 through FY2015. [On Sept. 27, 2010, HHS announced Health Profession Opportunity Grant awards totaling $67 million. See http://www.hhs.gov/news/press/ 2010pres/09/20100927e.html.] [On Oct. 26, 2010, HHS announced the availability of $4 million to support family-to-family information centers. See http://www.hhs.gov/ news/press/2010pres/10/20101026f.html.] [On Jan. 25, 2011, HRSA announced the designation of 11 new THCs, who will receive GME payments for their new residents. See http://www.hrsa.gov/about/news/pressreleases/ 110125teachinghealthcenters.html.] PPACA Section New/Existing Authority Program Description Appropriation/Transfer 5509 New authority Medicare graduate nurse education demonstration program. Requires the Secretary to establish a Medicare demonstration program under which up to five eligible hospitals will receive reimbursement for providing advanced practice nurses with clinical training in primary care, preventive care, transitional care, and chronic care management. [CMS] Appropriates $50 million for each of FY2012 through FY2015, to remain available until expended. (Total amount = $200 million.) 10502 New authority Health care facility construction. Provides funding for debt service on, or construction or renovation of, a hospital affiliated with a state’s sole public medical and dental school. [HRSA] Appropriates $100 million for FY2010, to remain available for obligation until Sept. 30, 2011. [On Dec. 29, 2010, HRSA announced a $100 million award to Ohio State University. See http://www.hrsa.gov/about/news/pressreleases/2010/ 101229ohiostate.html.] Community-Based Prevention and Wellness 4002 New authority Prevention and Public Health Fund (PPHF). Establishes a PPHF and appropriates amounts to the fund in perpetuity. Requires the Secretary to transfer amounts from the fund to HHS accounts to increase funding, over the FY2008 level, for PHSA-authorized prevention, wellness, and public health activities, including prevention research and health screenings. Authorizes House and Senate appropriators to transfer monies from the PPHF to eligible activities. [OS, CDC, HRSA] Appropriates the following amounts to the PPHF: FY2010 = $500 million; FY2011 = $750 million; FY2012 = $1 billion; FY2013 = $1.25 billion; FY2014 = $1.5 billion; FY2015 and each fiscal year thereafter = $2 billion. [For HHS’s announcements of FY2010 funding availability and grant awards, see (1) http://www.hhs.gov/news/press/2010pres/09/ 20100927e.html (primary care workforce grant awards: $253 million total); and (2) http://www.hhs.gov/news/press/2010pres/06/ 20100618g.html (funding opportunity announcements for community/clinical prevention initiatives, and public health infrastructure, systems, research, & training: approx. $250 million total). On Feb. 9, 2011, HHS announced the allocation of $750 million in FY2011 funds. See http://www.hhs.gov/news/press/2011pres/02/20110209b.html.] Maternal and Child Health 2951 New SSA Sec. 511 CRS-12 Maternal, infant, and early childhood home visiting program. Requires the Secretary to award grants to states, U.S. territories, and Indian tribes to develop and implement early childhood home visiting programs that adhere to evidence-based models of service delivery. Programs must establish benchmarks to measure improvements for the participating families in prenatal, maternal, and newborn health; child health and development; parenting skills; school readiness; juvenile delinquency; and family economic self-sufficiency. [HRSA, ACF] Appropriates the following amounts for the home visiting program: FY2010 = $100 million; FY2011 = $250 million, FY2012 = $350 million; FY2013 = $400 million; FY2014 = $400 million. (Total amount = $1.5 billion.) [On July 21, 2010, HHS announced home visiting grant awards totaling $87.5 million to all 50 states, DC, and the territories. See http://www.hhs.gov/news/press/2010pres/07/20100721a.html. On Sept. 29, 2010, it announced grants totaling $3 million to 13 Indian tribes and tribal organizations in 9 states. See http://www.acf.hhs.gov/news/press/ 2010/hrsa_award_3m.html. On Feb. 8, 2011, HRSA issued guidance for states to submit updated plans for their home visiting programs. See http://www.hrsa.gov/grants/manage/homevisiting/sir02082011.pdf.] PPACA Section 2953 New/Existing Authority New SSA Sec. 513 2954 Amends SSA Sec. 510 10211-10214 New authority Program Description Appropriation/Transfer Personal responsibility education programs. Establishes a state formula grant program to support evidence-based Personal Responsibility Education Programs (PREPs) designed to educate adolescents about abstinence, contraception, and adult preparation, including healthy life skills, educational and career success, and financial literacy. Also, requires the Secretary to award grants to implement innovative youth pregnancy prevention strategies and to target services at high-risk populations. [ACF] Appropriates $75 million for each of FY2010 through FY2014, of which $10 million each year is to be reserved for the youth pregnancy prevention grants. Funds are to remain available until expended. (Total amount = $375 million.) Abstinence education grants. Renews funding for the state formula grant program, authorized under SSA Sec. 510, to support abstinence education programs. Funds are awarded to states based on the proportion of low-income children in each state compared to the national total, and may only be used for teaching abstinence. [ACF] Appropriates $50 million for each of FY2010 through FY2014. (Total amount = $250 million.) Pregnancy assistance grants. In collaboration with the Secretary of Education, requires the Secretary to establish a Pregnancy Assistance Fund for the purpose of awarding grants to states to assist pregnant and parenting teens and women. State grantees have the flexibility to make funds available to institutions of higher education, high schools and community service centers, and to the state attorneys general to improve services for pregnant women who are victims of domestic violence, sexual assault, or stalking. [OS] Appropriates $25 million for each of FY2010 through FY2019. (Total amount = $250 million.) Medicaid Money Follows the Person (MFP) demonstration program. Appropriates funding through FY2016 for the MFP demonstration, which authorizes the Secretary to award competitive grants to states to reduce their reliance on institutional care for people needing long-term care, and expand options for elderly people and individuals with disabilities to receive home and community-based longterm care services. [CMS] Appropriates $450 million for each of FY2011 through FY2016, to remain available through FY2016. (Total amount = $2.7 billion.) [On Sept. 30, 2010, HHS announced PREP grant awards totaling $55 million. See http://www.hhs.gov/news/press/2010pres/09/20100930a.html.] [On Sept. 30, 2010, HHS announced abstinence education grants totaling $33 million to 29 states and Puerto Rico. See http://www.hhs.gov/news/ press/2010pres/09/teenpregnancy_abstinencegrants.html.] [On Sept. 28, 2010, HHS announced pregnancy assistance grant awards totaling $24 million to 17 states and tribes. See http://www.hhs.gov/news/ press/2010pres/09/20100928d.html.] Long-Term Care 2403 Amends DRA Sec. 6071(h) CRS-13 [On Sept. 27, 2010, HHS announced a round of MFP funding totaling $10 million to 23 states and DC. See http://www.hhs.gov/news/press/ 2010pres/09/20100927a.html.] PPACA Section 2405 New/Existing Authority New authority 6201 New authority 8002(d) Amends DRA Sec. 6021(d) Program Description State Aging and Disability Resource Centers (ADRCs). Provides funding for ADRCs (authorized under Sec. 202 of the OAA), which serve as a single, coordinated resource for consumer information on the range of long-term care options in community and institutional settings. Some ADRCs also serve as the entry point to publicly administered long-term care programs (e.g., Medicaid, OAA services, state assistance programs). As of 2009, ADRC funding had expanded to include at least one site in each state, DC, and 3 U.S. territories (Guam, Puerto Rico, and Northern Mariana), with more than 200 sites nationwide. [AoA] Appropriation/Transfer Appropriates $10 million for each of FY2010 through FY2014. (Total amount = $50 million.) [On Sept. 27, 2010, HHS announced ADRC grants totaling $10 million to 19 states and DC. See http://www.hhs.gov/news/press/2010pres/09/ 20100927a.html.] Background checks of long-term care providers. Requires the Secretary to establish a nationwide program for background checks on direct patient access employees of long-term care facilities or providers, and to provide federal matching funds to states to conduct these activities. [CMS] Requires the Treasury Secretary to transfer to HHS an amount, not to exceed $160 million, that is specified by the HHS Secretary as necessary to carry out the program for the period FY2010 through FY2012. Funds are to remain available until expended. National Clearinghouse for Long-Term Care Information. Extends funding for the National Clearinghouse for Long-Term Care Information through FY2015, and requires the Clearinghouse to include information on the Community Living Assistance Services and Supports (CLASS) program, established under PPACA Sec. 8002(a). [CMS] Appropriates $3 million for each of FY2011 through FY2015 for the Clearinghouse. (Total amount = $15 million.) [For information on an initial round of grant awards totaling $14 million to 6 states, see http://aging.senate.gov/record.cfm?id=328161.] Comparative Effectiveness Research 6301(d)-(e) CRS-14 New IRC Secs. 9511, 4375, & 4376. New SSA Sec. 1183 Patient-Centered Outcomes Research Trust Fund (PCORTF). Establishes a PCORTF to fund the new Patient-Centered Outcomes Research Institute and its comparative effectiveness research activities. The fund is to receive the following amounts: (1) specified annual appropriations for each of FY2010 through FY2019 (see amounts in the right-hand column); (2) additional annual appropriations for each of FY2013 through FY2019 equal to the net revenue from a new fee levied on health insurance policies and self-insured plans;c and (3) transfers from the Medicare trust funds for each of FY2013 through FY2019.d [OS, AHRQ] Appropriates to the PCORTF $10 million for FY2010, $50 million for FY2011, and $150 million for each of FY2012 through FY2019, for a total of $1.26 billion over that 10-year period. For each of FY2013 through FY2019, the PCORTF is to receive additional appropriations based on the revenue from the health insurance policy/plan fee, as well as Medicare trust fund transfers. Each fiscal year, 20% of the funds in the PCORTF are to be transferred to the Secretary. PPACA Section New/Existing Authority Program Description Appropriation/Transfer Biomedical Research 9023 New IRC Sec. 48D Therapeutic research and development tax credits and grants. Creates a two-year tax credit program, subject to an overall cap of $1 billion, for small companies (250 or fewer employees) that invest in new therapies to prevent, diagnose, and treat cancer and other diseases. Companies may apply for one or more tax credits, each covering up to 50% of the cost of qualifying research investments made in 2009 and 2010. However, the total amount of tax credits any one company receives for the two years may not exceed $5 million. Companies may elect to receive one or more grants in lieu of tax credits, subject to the same restrictions (i.e., grants may cover up to 50% of the cost of qualifying investments made in 2009 and 2010; the total amount of grants any one company receives for the two years may not exceed $5 million). [IRS] Appropriates SSAN to carry out the grant program. Health Insurance Reform Implementation Fund (HIRIF). Establishes an HIRIF for federal administrative expenses to carry out PPACA and HCERA. [OS] Appropriates $1 billion to the HIRIF. [For a list of all the companies and their research projects that the IRS has approved, and the tax credit or grant award for each approved project, see http://www.irs.gov/businesses/small/article/0,,id=228690,00.html.] PPACA Implementation HCERA Sec. 1005 New authority Source: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (PPACA; P.L. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (HCERA; P.L. 111-152). a. Transfers from the two trust funds are in such proportion as the Secretary determines appropriate. b. Of the amounts appropriated for the period FY2011 through FY2019 and for each subsequent 10-fiscal year period, at least $25 million must be made available each fiscal year for the selection, testing, and evaluation of new payment and service delivery models. c. The health insurance fee is to equal $2 multiplied by the average number of covered lives in a policy/plan year ($1 in the case of a policy/plan year ending during FY2013), updated annually by the rate of medical inflation beginning in FY2015. d. The trust fund transfers are to equal $2 multiplied by the average number of individuals entitled to benefits under Part A or enrolled under Part B in a given fiscal year ($1 in FY2013), updated annually by the rate of medical inflation beginning in FY2015. CRS-15 Table 2. Appropriations and Fund Transfers in the Health Reform Law, FY2010-FY2019 Patient Protection and Affordable Care Act (PPACA; P.L. 111-148, as amended by P.L. 111-152) PPACA Section Appropriation (or Fund Transfer) in $ millions Program FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 FY2016 FY2017 FY2018 FY2019 Total Private Health Insurance 1002 Health insurance consumer information 30a 1003 Review of health insurance premium rates 250 — — — — — — — — — 250 1101 Temporary high-risk health insurance pools 5,000a — — — — — — — — — 5,000 1102 Early retiree reinsurance program 5,000a — — — — — — — — — 5,000 1311 Health insurance exchange planning and establishment Appropriates necessary amounts for grants each fiscal year, as determined by the Secretary; no grants may be awarded after Jan. 1, 2015 — — — — TBDb 1322 Consumer operated and oriented plans (CO-OPs) — — — — 6,000 1323 Health insurance exchange subsides (U.S. territories) Authorizes to be appropriated SSAN for FY2011 and each fiscal year thereafter 6,000 — — — — — — — — — 30 1,000 $1 billion total for CY2014 through CY2109c Medicaid and Children’s Health Insurance Program (CHIP) 2701 Medicaid adult health quality measures 60 60 60 60 60 — — — — — 300d 2707 Medicaid emergency psychiatric demonstration — 75e — — — — — — — — 75 2801 Medicaid and CHIP Payment and Access Commission 11f 4108 Medicaid prevention and wellness incentives — 4306 CHIP childhood obesity demonstration 10203(d) CHIP annual appropriationg CRS-16 Authorizes to be appropriated SSAN for FY2011 and each fiscal year thereafter — — — — — 100 — — — — — 25 21,061 — — — — 40,208 $100 million total for CY2011 through CY2015d $25 million total for FY2010 through FY2014 — — — 19,147 11 PPACA Section 10203(d) Appropriation (or Fund Transfer) in $ millions Program CHIP outreach and enrollment grants FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 Increases total funding from $100 million to $140 million and extends funding period through FY2015 FY2016 FY2017 FY2018 FY2019 Total — — — — 40 — — — — 100 Medicare 3014 Medicare quality and efficiency measures 3021(a) Center for Medicare and Medicaid Innovation 5 3024 Medicare independence at home demonstration 5h 3026 Community-based care transition services — 3027(b) Medicare gainsharing demonstration 2 — — — — 3113 Diagnostic laboratory test demonstration 5i — — — 3306 Outreach and assistance for low-income beneficiaries $45 million total for FY2010 through FY2012 — 3403 Independent Payment Advisory Board 4202(b) 20h 20 20 20 20 — plus $10 billion total for FY2011 through FY2019, and $10 billion for each subsequent 10-fiscal year period 5 5 5 5 5 10,005d — — — — 30 — — — — 500 — — — — — 2d — — — — — — 5 — — — — — — 45d $500 million total for FY2011 through FY2015h For FY2013 and each subsequent fiscal year, appropriates previous year’s amount adjusted for inflation; funds derived from the Medicare Part A and Part B trust funds. — — 15 Prevention and wellness evaluation 50h — — — — — — — — — 50 4204(e) GAO study of Medicare vaccine coverage 1 — — — — — — — — — 1 10323(a) Environmental health pilot program 10323(b) Environmental health screening and education TBDb TBDb SSANh $20 million total for FY2015 though FY2019, and for each 5fiscal year period thereafter $23 million total for FY2010 through FY2014 43d Fraud and Abuse 6402(i) & HCERA 1303(a) CRS-17 Health Care Fraud and Abuse Control (HCFAC) Account — 105 65 40 40 30 30 10 10 10 350j PPACA Section Appropriation (or Fund Transfer) in $ millions Program FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 FY2016 FY2017 FY2018 FY2019 Total Health Centers and the National Health Service Corps (NHSC) 4101(a) School-based health center establishment grants 50 50 50 50 — — — — — — 200d 10503(b)(1) Community Health Centers Fund, patient services — 1,000 1,200 1,500 2,200 3,600 — — — — 9,500d 10503(b)(2) Community Health Centers Fund, NHSC — 290 295 300 305 310 — — — — 1,500d 10503(c) Community health center construction and renovation — — — — — 1,500d $1.5 billion total for FY2011 through FY2015 Health Workforce 5507(a) Health workforce demonstration grants 85 85 85 85 85 — — — — — 425 5507(b) Family-to-family health information centers 5 5 5 — — — — — — — 15d 5508(c) Teaching health centers, GME payments — — — — — ≤230 5509 Medicare graduate nurse education demonstration — — 50 50 50 50 — — — — 200d 10502 Health care facility construction 100 — — — — — — — — — 100k 500 750 1,000 1,250 1,500 2,000 2,000 2,000 2,000 2,000 15,000l SSAN for FY2011 through FY2015, not to exceed $230 million Community-Based Prevention and Wellness 4002 Prevention and Public Health Fund Maternal and Child Health 2951 Maternal, infant, and early childhood home visitation 100 250 350 400 400 — — — — — 1,500 2953 Personal responsibility education program grants 75 75 75 75 75 — — — — — 375d 2954 Abstinence education state grants 50 50 50 50 50 — — — — — 250 CRS-18 Appropriation (or Fund Transfer) in $ millions PPACA Section Program 10214 Pregnancy assistance grants FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 FY2016 FY2017 FY2018 FY2019 Total 25 25 25 25 25 25 25 25 25 25 250 Long-Term Care 2403 Medicaid money follows the person demonstration — 450 450 450 450 450 450 — — — 2,700 2405 State Aging and Disability Resource Centers 10 10 10 10 10 — — — — — 50 6201 Background checks of longterm care providers — — — — — — — 8002(d) National Clearinghouse for Long-Term Care Information 3 3 3 — — — — Up to $160 million total for FY2010 through FY2012m — 3 3 15 Comparative Effectiveness Research 6301(d) Patient-Centered Outcomes Research Trust Fund, Medicare transfers — — — For each of FY2013 through FY2019, transfers amounts from the Medicare trust funds as determined by a formulan TBDb 6301(e) Patient-Centered Outcomes Research Trust Fund, appropriations 10 50 150 For each of FY2013 through FY2019, appropriates $150 million plus an amount equal to the net revenue from a fee levied on insurance policies and health planso TBDb SSAN — — — — — — — — — TBDp 1,000 — — — — — — — — — 1,000 Biomedical Research 9023(e) Grants for investment in new therapeutics PPACA Implementation HCERA 1005 Health Insurance Reform Implementation Fund Source: Prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (PPACA), P.L. 111-148, as amended by the Health Care and Education Reconciliation Act of 2010 (HCERA), P.L. 111-152. Notes: Funds are provided from the Treasury unless otherwise noted. A dash means that PPACA does not appropriate or transfer funds for the fiscal year(s) noted. a. Funds are to remain available without fiscal year limitation. b. To be determined. c. Of this total amount, $925 million is for Puerto Rico, and the remaining $75 million is for the other U.S. territories in amounts as specified by the Secretary. CRS-19 d. Funds are to remain available until expended. e. Funds are to remain available for obligation through Dec. 31, 2015. f. Of this total amount, $9 million is appropriated, and the remaining $2 million is a transfer from CHIP funding for FY2010. Funds are to remain available until expended. g. Prior to enactment of PPACA, the CHIP program was funded through FY2013. h. The Secretary is required to transfer amounts from the Medicare Part A and Part B trust funds in such proportion as the Secretary determines appropriate. Funds are to remain available until expended, i. The Secretary is required to transfer the $5 million from the Medicare Part B trust fund, to remain available until expended. j. Funds are to be appropriated from the Medicare Part A trust fund. Note: the total amount appropriated (i.e., $350 million) includes a final appropriation of $10 million for FY2020. k. Funds are to remain available for obligation until Sept. 30, 2011. l. PPACA Sec. 4002 provides annual appropriations for the Prevention and Public Health Fund in perpetuity; increasing from $500 million for FY2010 to $2 billion for FY2015 and each fiscal year thereafter. Appropriations to the fund total $15 billion over the period FY2010 through FY2019. m. PPACA Sec. 6201 requires the HHS Secretary to notify the Treasury Secretary of the amount necessary to carry out activities under this section for the period of FY2010 through FY2012, but not to exceed $160 million. The Treasury Secretary must then transfer the amount specified from the Treasury to the HHS Secretary. Funds are to remain available until expended. n. To be determined. PPACA Sec. 6301(d) provides a formula for the transfer of funds from the Medicare Part A and Part B trust funds to the Patient-Centered Outcomes Research Trust Fund as follows: (1) for FY2013, an amount from each respective Medicare trust fund equal to $1 multiplied by the average number of individuals entitled to Part A benefits, or enrolled in Part B during that period; and (2) for each of FY2014 through FY2019, an amount from each respective Medicare trust fund equal to $2 multiplied by the average number of individuals entitled to Part A benefits, or enrolled in Part B during that fiscal year. Beginning in FY2015, amounts are subject to adjustment for increases in health care spending. o. To be determined. In addition to the amounts transferred to the Patient-Centered Outcomes Research Trust Fund under PPACA Sec. 6301(d), described in the preceding table note, PPACA Sec. 6301(e) appropriates to the Fund a specified amount for each of FY2010 through FY2019 plus an additional amount for each of FY2013 through FY2019 equal to the net revenues received from a fee imposed on health insurance policies and self-insured plans. The fee equals $2 multiplied by the average number of covered lives in a policy/plan year ($1 in the case of policy/plan years ending during FY2013). Beginning in FY2015, amounts are subject to adjustment for increases in health care spending. p. To be determined. PPACA Sec. 9023(e) creates a two-year tax credit program, subject to an overall cap of $1 billion, for small companies that invest in new therapies to prevent, diagnose and treat cancer and other diseases. The total amount of tax credits any one company can receive for the two years may not exceed $5 million. Companies may elect to receive one or more grants—for which SSAN are appropriated—in lieu of tax credits. Grant applications must be received before Jan. 1, 2013. CRS-20 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act Author Contact Information C. Stephen Redhead Specialist in Health Policy credhead@crs.loc.gov, 7-2261 Acknowledgments Kirsten Colello, Patricia Davis, Gary Guenther, Elayne Heisler, Lisa Herz, Sarah Lister, Bernice Reyes, Amanda Sarata, Pam Smith, Carmen Solomon-Fears, Emilie Stoltzfus, Julie Stone, and Susan Thaul provided comments on this report. Congressional Research Service 21The Patient Protection and Affordable Care Act (ACA)1 made significant changes to the way health care is financed, organized, and delivered in the United States. Among its many provisions, ACA restructures the private health insurance market, sets minimum standards for health coverage, and, beginning in 2014, mandates that most U.S. residents obtain health insurance coverage or pay a penalty. The law provides for the establishment by 2014 of state-based health insurance exchanges for the purchase of private health insurance. Qualifying individuals and families will be able to receive federal subsidies to reduce the cost of purchasing coverage through the exchanges. In addition to expanding private health insurance coverage, ACA, as enacted, requires state Medicaid programs to expand coverage to all eligible nonelderly, non-pregnant individuals under age 65 with incomes up to 133% of the federal poverty level (FPL). States that elect not to expand their Medicaid programs risk losing their existing federal Medicaid matching funds. Under ACA, the federal government will initially cover 100% of the expansion costs, phasing down to 90% of the costs by 2020. On June 28, 2012, the U.S. Supreme Court, in National Federation of Independent Business v. Sebelius, found that the Medicaid expansion violated the Constitution by threatening states with the loss of their existing federal Medicaid matching funds.2 The Court precluded the Secretary of Health and Human Services (HHS) from penalizing states that choose not to participate in the Medicaid expansion (see text box below). ACA also amends the Medicare program in an effort to reduce the rate of its projected growth; imposes an excise tax on insurance plans found to have high premiums; and makes many other changes to the tax code, Medicare, Medicaid, the State Children’s Health Insurance Program (CHIP), and other federal programs. ACA included numerous appropriations that provide billions of dollars to support new and existing grant programs and other activities. Several other provisions require the HHS Secretary to transfer amounts from the Medicare Part A and Part B trust funds for specified purposes. This report summarizes all these mandatory spending provisions3 and, using publicly available information, provides details on the status of obligation of the funds. It also includes a brief discussion of ACA-related discretionary spending, which is provided in and controlled by annual appropriations acts. Finally, the report provides some analysis of the impact that a sequestration triggered by the Budget Control Act might have on ACA mandatory spending in FY2013. This report is periodically revised and updated to reflect important legislative and other developments. 1 ACA was signed into law on March 23, 2010 (P.L. 111-148, 124 Stat. 119). A week later, on March 30, 2010, the President signed the Health Care and Education Reconciliation Act (HCERA; P.L. 111-152, 124 Stat. 1029), which amended multiple health care and revenue provisions in ACA. Several other bills that were subsequently enacted during the 111th and 112th Congresses made more targeted changes to specific ACA provisions (see Appendixes B and C). All references to ACA in this report refer to the law as amended. Note that previous CRS reports on the Patient Protection and Affordable Care Act used the acronym PPACA to refer to the law. CRS is now using the more common acronym ACA. 2 NFIB v. Sebelius, No. 11-393, slip op. (June 28, 2012), available at http://www.supremecourt.gov/opinions/11pdf/11393c3a2.pdf. 3 Mandatory spending, also known as direct spending, refers to outlays from budget authority (i.e., the authority to incur financial obligations that result in government expenditures) that is provided in laws other than annual appropriations acts. Mandatory spending includes spending on entitlement programs. Congressional Research Service 1 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act U.S. Supreme Court Decision on ACA (June 28, 2012) In National Federation of Independent Business v. Sebelius (NFIB) the Court ruled on the constitutionality of both the individual mandate, which requires most U.S. residents (beginning in 2014) to carry health insurance or pay a penalty, and the Medicaid expansion. The Court upheld the individual mandate as a constitutional exercise of Congress’s authority to levy taxes. The penalty is to be paid by taxpayers when they file their tax returns and enforced by the Internal Revenue Service. In a separate opinion, the Court found that compelling states to participate in the ACA Medicaid expansion—which the Court determined to be essentially a new program—or risk losing their existing federal Medicaid matching funds was coercive and unconstitutional under the Spending Clause of the Constitution and the Tenth Amendment. The Court’s remedy for this constitutional violation was to prohibit HHS from penalizing states that choose not to participate in the expansion by withholding any federal matching funds for their existing Medicaid program. However, if a state accepts the new ACA expansion funds (initially a 100% federal match), it must abide by all the expansion coverage rules. Under NFIB v. Sebelius, all other provisions of ACA remain fully intact and operative. For more information, see CRS Report R42698, NFIB v. Sebelius: Constitutionality of the Individual Mandate, by Erika K. Lunder and Jennifer Staman; and CRS Report R42367, Medicaid and Federal Grant Conditions After NFIB v. Sebelius: Constitutional Issues and Analysis, by Kenneth R. Thomas. Mandatory Appropriations and Fund Transfers in ACA ACA appropriated billions of dollars for a number of short-term health care programs for targeted groups, including (1) $5 billion for the Pre-Existing Condition Insurance Plan (PCIP), a temporary insurance program to provide health insurance coverage for uninsured individuals with a preexisting condition; (2) $5 billion for a temporary reinsurance program to reimburse employers for a portion of the costs of providing health benefits to early retirees aged 55-64; and (3) $6 billion for the Consumer Operated and Oriented Plan (CO-OP) program, to establish temporary health insurance cooperatives. ACA also included money for states to plan and establish health insurance exchanges. The law created a Center for Medicare and Medicaid Innovation (CMMI) within the Centers for Medicare and Medicaid Services (CMS), and appropriated $10 billion for the FY2011-FY2019 period—and $10 billion for each subsequent 10-year period—for CMMI to test and implement innovative payment and service delivery models. It also established and funded an Independent Payment Advisory Board (IPAB) to make recommendations to Congress for achieving specific Medicare spending reductions if costs exceed a target growth rate. IPAB’s recommendations are to take effect unless Congress overrides them, in which case Congress would be responsible for achieving the same level of savings. ACA also established four special funds and appropriated substantial amounts to each. First, the Community Health Center Fund (CHCF) will provide a total of $11 billion in annual appropriations over five years (FY2011-FY2015) for community health center operations and the National Health Service Corps. A separate ACA appropriation provided $1.5 billion for health center construction and renovation. While CHCF funding may have been intended to supplement annual discretionary appropriations for health centers and the NHSC program, the funds have Congressional Research Service 2 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act partially supplanted discretionary health center funding and have become the sole source of funding for the NHSC program, which received no discretionary funds in FY2012.4 Second, the Patient-Centered Outcomes Research Trust Fund (PCORTF) will support comparative effectiveness research through FY2019 with a mix of annual appropriations—some of which are offset by revenues from a fee imposed on private health plans—and transfers from the Medicare Part A and Part B trust funds. Third, the Prevention and Public Health Fund (PPHF), for which ACA provided a permanent annual appropriation, is intended to support prevention, wellness, and other public health-related programs and activities authorized under the Public Health Service Act (PHSA).5 PPHF funds have been used to support several new discretionary grant programs authorized by ACA. The funds are also supplementing, and in some cases supplanting, annual discretionary appropriations for a number of established programs, including ones that were reauthorized by ACA (see discussion below under “Discretionary Spending in ACA”). Fourth, ACA provided $1 billion to the Health Insurance Reform Implementation Fund (HIRIF) to help cover the administrative costs of implementing the law. In addition, ACA appropriated $2.4 billion for maternal and child health programs. Overall, the law included more than $100 billion in direct appropriations over the 10-year period FY2010FY2019, including $40 billion to provide two more years of funding for CHIP. Table 1 summarizes all the ACA provisions that include an appropriation of funds, or a transfer of amounts from the Medicare trust funds. The provisions are grouped under the following headings: (1) Private Health Insurance; (2) Medicaid and the State Children’s Health Insurance Program (CHIP); (3) Medicare; (4) Fraud and Abuse; (5) Health Centers and the National Health Service Corps (NHSC); (6) Health Workforce; (7) Community-Based Prevention and Wellness; (8) Maternal and Child Health; (9) Long-Term Care; (10) Comparative Effectiveness Research; (11) Biomedical Research; and (12) ACA Implementation: Administrative Expenses. Each table row provides information on a specific ACA provision, organized across four columns. The first column shows the ACA section or subsection number. The second column indicates whether the provision is freestanding (i.e., new statutory authority that is not amending an existing statute) or amendatory (i.e., amends an existing statute such as the PHSA, either by adding a new program or amending an existing one). The third column gives a brief description of the program or activity, including details of the appropriation or fund transfer. The entry also includes the name of the administering HHS agency and, if applicable, the Catalog of Federal Domestic Assistance (CFDA) number for the grant program.6 The fourth column shows the amount of obligations to date, based on information in the HHS Tracking Accountability in Government Grants System (TAGGS), unless specified otherwise. The TAGGS database is a central repository for grants awarded by all the HHS operating divisions (agencies) and several 4 For more information, see CRS Report R42433, Federal Health Centers, by Elayne J. Heisler. Section 3205 of the Middle Class Tax Relief and Job Creation Act of 2012 (P.L. 112-96, 126 Stat. 156) reduced ACA’s appropriations to the PPHF over the period FY2013-FY2021 by a total of $6.25 billion. Under ACA, the PPHF would have received a total of $16.75 billion over that nine-year period; P.L. 112-96 reduced that amount to $10.50 billion. See Table 1 and Appendix B. 6 CFDA is a government-wide compendium of federal grant and other assistance programs. Each program is assigned a unique five-digit number, XX.XXX, where the first two digits represent the funding agency and the second three digits represent the program. Programs funded by the Department of Health and Human Services begin with the number 93. For more information, see https://www.cfda.gov. 5 Congressional Research Service 3 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act offices within the Office of the Secretary. It is updated daily with new data provided by these entities.7 Readers are also encouraged to visit the website of the Center for Consumer Information and Insurance Oversight (CCIIO, within CMS),8 which is responsible for implementing ACA’s private health insurance provisions, as well as HealthCare.gov, which is tracking ACA implementation state-by-state. Both sites include factsheets, press releases, and other information on the ACA grant programs and activities summarized in this report. In many instances, ACA provides annual appropriations of specified amounts for one or more fiscal years. These funds must be obligated during the fiscal year in which the funds become available for obligation. A few provisions are multiple-year appropriations, in which the amount appropriated is available for obligation for a definite period of time in excess of one fiscal year (e.g., for the period FY2011 through FY2014). Often the provision includes additional language stating that the funds are to remain available “until expended” or “without fiscal year limitation.” One ACA provision (i.e., Section 1311) appropriates an unspecified amount—such sums as may be necessary, or SSAN—and authorizes the HHS Secretary to determine the amount necessary for the grant program.9 Generally, the ACA appropriations or fund transfers are for one or more fiscal years through FY2019. However, ACA includes four provisions (i.e., Sections 3021(a), 3403, 10323(b), and 4002) that continue to provide annual or multiple-year appropriations beyond FY2019. Table 2 provides additional details on each of the appropriations (and fund transfers) summarized in Table 1. It shows the amount available for obligation in each fiscal year (or multi-year period) over the 10-year period FY2010 through FY2019. Note that the provisions are organized and grouped under the same headings used in Table 1. The final column in Table 2 (“Total”) shows for each provision the cumulative amount of appropriations or fund transfers through FY2019. In several cases, that amount has yet to be determined (see table entries for ACA Sections 1311, 3403, 6301(d) & (e), 9023(e), and 10323(a)). For three of the provisions that provide appropriations beyond FY2019, the table shows the cumulative amount appropriated through FY2019 (see table entries for ACA Sections 3021(a), 4002, and 10323(b)). Unless otherwise stated, references to the Secretary in both tables refer to the HHS Secretary. A list of the acronyms used in this report is provided in Appendix A. Lawmakers opposed to specific provisions in ACA, or to the entire law, introduced numerous bills in the 112th Congress to modify or repeal the law, including legislation to eliminate some of the mandatory appropriations discussed in this report. Appendix B summarizes the ACA-related authorizing legislation enacted during the 112th Congress, as well as the House-passed bills that would have modified or repealed ACA. Appendix C summarizes the ACA-related provisions in annual appropriations acts for FY2011-FY2013. 7 To access and search the TAGGS database, go to http://www.taggs.hhs.gov/. http://cciio.cms.gov 9 Two other ACA provisions (i.e., Sections 5508(c), and 9023(e)) also appropriate SSAN to carry out a program, but in each case there is an upper limit on the amount that may be appropriated. Another provision (i.e., Section 10323(a)) requires the HHS Secretary to transfer SSAN from the Medicare trust funds to carry out a pilot program. 8 Congressional Research Service 4 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act Discretionary Spending in ACA In addition to its impact on mandatory spending, implementation of ACA is having an effect on discretionary spending, which is provided in and controlled by annual appropriations acts. The law reauthorized appropriations for numerous existing discretionary grant programs and activities authorized under the PHSA. While the authorizations of appropriations for many of those programs expired prior to their reauthorization in ACA, most of them continued to receive an annual appropriation. ACA also created a number of new discretionary grant programs and provided for each an authorization of appropriations. Funding for all these discretionary programs will depend on future action taken by congressional appropriators. However, with the renewed emphasis on reducing federal spending, it may prove difficult to secure funding for new programs and activities. Even existing programs with an established appropriations history may find it a challenge to maintain funding at current levels. A companion product, CRS Report R41390, Discretionary Spending in the Patient Protection and Affordable Care Act (ACA), provides more detailed analysis of all the provisions in ACA that provide an authorization of appropriations for an existing or new program. In addition to discretionary spending on grant programs authorized (or reauthorized) by ACA, the Congressional Budget Office (CBO) estimates that both HHS and the Internal Revenue Service (IRS) will incur substantial administrative costs to implement the policies established by ACA. The IRS is responsible for implementing the eligibility determination, documentation, and verification processes for ACA’s health exchange subsidies, while HHS must implement numerous changes to Medicare, Medicaid, and CHIP, as well as some of the reforms to the private health insurance market. As already noted, ACA established a $1 billion implementation fund (i.e., HIRIF) to help cover the administrative expenses associated with implementing the law. While HHS has used the HIRIF to cover its own ACA administrative costs, the department has transferred a significant portion of HIRIF funding to the IRS. HHS projected that all the HIRIF funds would be obligated by the end of FY2012. Thereafter, ACA administrative costs will have to be funded through annual discretionary appropriations (see Appendix C). Potential Impact of Spending Cuts Under the Budget Control Act The Budget Control Act of 2011 (BCA) included procedures and a timetable for enactment of a bill to reduce the federal deficit.10 In the event that Congress and the President failed to enact such legislation, as was the case, the BCA required the President to order across-the-board spending cuts—a process known as sequestration—for all nonexempt direct (i.e., mandatory) and discretionary spending programs on January 2, 2013. That deadline was delayed for two months, until March 1, 2013, by the American Taxpayer Relief Act of 2012 (ATRA).11 ATRA also reduced the total amount of spending cuts for FY2013 by $24 billion, from $109.33 billion to $85.33 10 11 P.L. 112-25, 125 Stat. 240. P.L. 112-240, 126 Stat. 2313. Congressional Research Service 5 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act billion. This final section of the report provides an overview of the BCA’s mechanisms for reducing spending. As discussed below, a FY2013 sequestration would impact many of the ACA mandatory appropriations summarized in this report. BCA Background The BCA authorized the President to increase the nation’s debt limit by at least $2.1 trillion (and up to $2.4 trillion under certain conditions) in three installments and established procedures designed to reduce future federal spending by a comparable amount.12 To achieve the spending reductions, the law placed enforceable limits, or caps, on discretionary spending for each of FY2012 through FY2021. CBO estimated that adhering to these limits, which grow by approximately 2% each year, would reduce federal spending by $917 billion through FY2021, compared to the projected level of spending if annual appropriations were to grow at the rate of inflation.13 In addition, the BCA created a Joint Select Committee on Deficit Reduction (Joint Committee) and instructed it to develop deficit-reduction legislation for Congress to consider under expedited floor procedures. If, by January 15, 2012, Congress and the President failed to enact a Joint Committee bill reducing the deficit by an amount greater than $1.2 trillion over the period FY2012-FY2021, then automatic annual spending reductions would be triggered beginning in FY2013. On November 21, 2011, the Joint Committee announced that it was unable to agree on a deficit-reduction bill. This meant that automatic spending reductions totaling $1.2 trillion were set to take effect, pursuant to the procedures and timetable established in the BCA, unless new legislation to modify or repeal the law was enacted. Based on the formula in the BCA, the automatic spending reductions would cut $109.33 billion for each fiscal year over the period FY2013-FY2021. [Note: ATRA’s $24 billion adjustment for FY2013 is discussed below.] Each year’s cut would be equally divided between defense and nondefense spending. The annual spending reduction in each of these two categories (i.e., $54.67 billion) would be further divided proportionately between discretionary spending and nonexempt direct (i.e., mandatory) spending. In FY2013, both the discretionary and the direct spending reductions in the two categories would be achieved through sequestration—a largely across-theboard cancellation of budgetary resources in nonexempt accounts. In each of the remaining fiscal years through FY2021, discretionary spending reductions would be achieved through a downward adjustment of the BCA spending limits, while direct spending reductions would continue to be executed through sequestration. Under the sequestration rules, reductions in Medicare payments to health care providers and health plans (which account for most of Medicare spending) are capped at 2%. Many other federal direct spending programs, accounting for most of the government’s entitlement and other direct spending (excluding Medicare), are exempt from sequestration altogether.14 12 For a more detailed examination of all the provisions in the BCA, see CRS Report R41965, The Budget Control Act of 2011, by Bill Heniff Jr., Elizabeth Rybicki, and Shannon M. Mahan. 13 U.S. Congressional Budget Office, Analysis of Budget Control Act, August 1, 2011. Available at http://www.cbo.gov/publication/41626. 14 The sequestration exemptions and rules are specified in sections 255 and 256, respectively, of the Balanced Budget and Emergency Deficit Control Act (BBEDCA). For more information, see CRS Report R42050, Budget “Sequestration” and Selected Program Exemptions and Special Rules, coordinated by Karen Spar. Congressional Research Service 6 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act Discretionary spending reductions in FY2013 also would be achieved through a sequestration of nonexempt discretionary appropriations. The sequestration rules exempt some discretionary spending, notably for veterans’ health care and Pell grants.15 For each of the remaining fiscal years (i.e., FY2014-FY2021), discretionary spending reductions would be achieved by lowering the BCA discretionary spending caps. There would be no across-the-board cuts through sequestration. Instead, the Appropriations Committees would decide how to apportion the cuts within the reduced cap. The BCA requires the OMB to calculate, and the President to order, a sequestration of nonexempt discretionary appropriations for FY2013 and nonexempt direct spending for each of FY2013 through FY2021. As already noted, the sequestration for FY2013 was to be ordered on January 2, 2013. However, ATRA amended the BCA by delaying the sequestration order by two months. The President is now instructed to order a FY2013 sequestration on March 1, 2013. The BCA requires the sequestrations for subsequent fiscal years (i.e., FY2014-FY2021) to occur at the time of the President’s annual budget submission in early February. FY2013 Nondefense Direct Spending Reductions On September 14, 2012, OMB released a report on the potential impact of a sequestration triggered by the failure of the Joint Committee to propose, and Congress and the President to enact, legislation to reduce the deficit by an amount greater than $1.2 trillion.16 The OMB report provided a breakdown of exempt and nonexempt budget accounts, and included estimates of the FY2013 funding reductions in nonexempt accounts. OMB calculated that sequestration would result in a 7.6% reduction in nonexempt nondefense direct (i.e., mandatory) spending. OMB emphasized that the estimates and budget account classifications in the report are preliminary. The agency noted that “[i]f the sequestration were to occur, the actual results would differ based on changes in law and ongoing legal, budgetary, and technical analysis.”17 In addition to delaying the FY2013 sequestration order, ATRA reduced the FY2013 sequestration by $24 billion, from $109.33 billion to $85.33 billion. Because the sequestration is divided equally between defense and nondefense spending, each of these two spending categories would be subject to $12 billion less in spending cuts (i.e., $42.67 billion, instead of $54.67 billion). Importantly, OMB’s preliminary estimates of the potential impact of a FY2013 sequestration predate ATRA’s enactment and, therefore, do not take into account the $24 billion reduction. Applying that adjustment to OMB’s calculations significantly reduces the estimated percentage reduction in nonexempt nondefense direct (i.e., mandatory) spending under a FY2013 sequestration order. The mandatory appropriations in ACA would, in general, be fully sequestrable at the rate applicable to nonexempt nondefense mandatory spending. However, for any given fiscal year in which sequestration was ordered, only new budget authority for that year (including advance appropriations that first become available for obligation in that year) would be reduced. 15 Ibid. Note that all veterans programs, mandatory and discretionary, are exempt from sequestration. U.S. Office of Management and Budget, OMB Report Pursuant to the Sequestration Transparency Act of 2012 (P.L. 112-155), http://www.whitehouse.gov/sites/default/files/omb/assets/legislative_reports/stareport.pdf. 17 Ibid., p. 1. 16 Congressional Research Service 7 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act Unobligated balances (nondefense only) carried over from previous fiscal years are exempt from a sequestration order.18 Thus, an FY2013 sequestration order to reduce direct spending would not apply to unobligated ACA funds that had been appropriated in a prior fiscal year (i.e., FY2010FY2012) and were still available for obligation. The exemption for unobligated balances carried over from prior fiscal years would apply to a number of ACA appropriations. As already mentioned, the appropriation provision often specifies that the funds are to remain available “until expended” or “without fiscal year limitation.” One example is the PCIP program to provide health insurance coverage for eligible individuals who have been uninsured for six months and have a preexisting condition. The program terminates on January 1, 2014. ACA appropriated $5 billion in FY2010, to remain available without fiscal year limitation, to pay claims against the PCIP that are in excess of the premiums collected from enrollees. Any unobligated PCIP funds in FY2013 would be exempt from sequestration. According to OMB’s preliminary analysis, the FY2013 appropriations for both PPHF and PCORTF would also be fully sequestrable at the rate applicable to nonexempt nondefense mandatory spending. However, the reduction in CHCF funding would be capped at 2%. For more discussion and analysis of the effect of BCA-triggered spending reductions on ACA mandatory (and discretionary) spending in FY2013, see CRS Report R42051, Budget Control Act: Potential Impact of Sequestration on Health Reform Spending, by C. Stephen Redhead. 18 An exemption for nondefense unobligated balances is provided in BBEDCA Section 255(e). It reads as follows: “Unobligated balances of budget authority carried over from prior fiscal years, except balances in the defense category, shall be exempt from reduction under any order issued under this part.” 2 U.S.C. §905(e). Congressional Research Service 8 Table 1. Summary of Mandatory Appropriations and Medicare Trust Fund Transfers in the Affordable Care Act ACA Section Statutory Authority Program Obligations as of January 4, 2013, Based on TAGGS Unless Specified Otherwise Title I – Private Health Insurance 1002 1003 1101 1102 New PHSA Sec. 2793 Consumer Assistance Program (CAP). Appropriates $30 million, to remain available without fiscal year limitation, for CAP grants to states to enable them (or the exchanges operating in such states) to establish, expand, or provide support for offices of health insurance consumer assistance, and health insurance ombudsman programs. [CMS/CCIIO; CFDA 93.519] $46 million New PHSA Sec. 2794 Review of health insurance premium rates. Appropriates $250 million for grants to states over the five-year period FY2010-FY2014 to support programs that review annual increases in health insurance premiums. No state may receive less than $1 million or more than $5 million in a grant year. Funds remaining unobligated at the end of FY2014 are to remain available for grants to states for planning and implementing ACA’s individual and group market reforms. [CMS/CCIIO; CFDA 93.511] $159 million New authority Pre-Existing Condition Insurance Plan (PCIP). Requires the Secretary to establish a temporary program—PCIP—to provide health insurance coverage for eligible individuals who have been uninsured for six months and have a pre-existing condition. The PCIP is federally administered in 23 states and DC; the remaining states administer their own PCIP programs. Appropriates $5 billion, to remain available without fiscal year limitation, to pay claims against (and administrative costs of) the PCIP that are in excess of premiums collected from enrollees. [CMS/CCIIO; CFDA 93.529] According to the most recent quarterly update, net PCIP outlays through September 2012 totaled $1.861 billion. Early Retiree Reinsurance Program (ERRP). Requires the Secretary to establish a temporary ERRP, ending on January 1, 2014, to provide reimbursement to participating employer-based plans for a portion of the cost of providing health benefits to early retirees age 55-64 and their families. Appropriates $5 billion, to remain available without fiscal year limitation, to carry out the ERRP. [CMS/CCIIO] According to the most recent program update, ERRP outlays through February 2012 totaled $4.73 billion. Health insurance exchange grants. Appropriates annually an amount (as determined by the Secretary) necessary to award exchange planning and establishment grants to states. No grants may be awarded after January 1, 2015, by which time exchanges must be selfsustaining. [CMS/CCIIO; CFDA 93.525] $2.049 billion Consumer Operated and Oriented Plan (CO-OP). Requires the Secretary to establish the CO-OP program to provide low-interest loans until July 1, 2013, for the creation of nonprofit member-run health insurance issuers that offer qualified health plans in the individual and small group markets. Appropriates $6 billion to carry out the CO-OP program. Note: P.L. 112-10 and P.L. 112-74 together rescinded a total of $2.6 billion of the original appropriation, and P.L. 112-240 rescinded all but 10% of the remaining unobligated funds; see Appendix C. [CMS/CCIIO; CFDA 93.545] According to a December 21, 2012 press release, the COOP program has awarded a total of $1.981 billion to 24 nonprofits offering coverage in 24 states. New authority 1311 New authority 1322 New authority CRS-9 [Total includes original funding plus recent (summer 2012) awards of additional funds. See http://cciio.cms.gov/ programs/consumer/capgrants/index.html.] [To date, two rounds of rate review grants have been awarded. See http://cciio.cms.gov/programs/marketreforms/ rates/index.html.] [PCIP has more than 90,000 enrollees to date. See http://cciio.cms.gov/programs/pcip/index.html.] [ERRP has provided payments to more than 2,800 employers and other sponsors of retiree plans. See http://cciio.cms.gov/programs/errp/index.html.] [See http://cciio.cms.gov/programs/exchanges/index.html.] [See http://cciio.cms.gov/programs/coop/index.html.] ACA Section 1323 Statutory Authority New authority Program Funding for territories. Appropriates $1 billion, available for the period FY2014-FY2019, for U.S. territories that elect to establish a health insurance exchange. Funds must be used to provide premium and cost-sharing assistance to territory residents who obtain health insurance coverage through the exchange. Obligations as of January 4, 2013, Based on TAGGS Unless Specified Otherwise No obligations. Title II – Medicaid and State Children’s Health Insurance Program (CHIP) 2701 New SSA Sec. 1139B Medicaid adult health quality measures. Requires the Secretary to develop and, not later than January 1, 2012, publish an initial core set of quality measures for Medicaideligible adults. Appropriates $60 million for each of FY2010-FY2014, to remain available until expended. Total amount = $300 million. [CMS; CFDA 93.609] Initial core set of measures published in January 2012. No public information located on funding obligations. 2707 New authority Medicaid emergency psychiatric demonstration program. Appropriates $75 million for FY2011, to remain available for obligation through December 2015, for a three-year demonstration in which eligible states are required to reimburse certain institutions for mental disease (IMDs) for services provided to Medicaid beneficiaries aged 21 through 64 who are in need of medical assistance to stabilize an emergency psychiatric condition. [CMS/CMMI; CFDA 93.537] CMS announced the 11 participating states (plus DC) in March 2012. No public information located on funding obligations. Amends SSA Sec. 1900 Medicaid and CHIP Payment and Access Commission (MACPAC). Clarifies and expands MACPAC’s duties; for example, to include a review and assessment of payment policies under Medicaid and CHIP and how factors affecting expenditures and payment methodologies enable beneficiaries to obtain services, affect provider supply, and affect providers that serve a disproportionate share of low-income and other vulnerable populations. Appropriates $9 million and transfers from CHIP funding an additional $2 million for FY2010. Total amount = $11 million, to remain available until expended. ACA funding was obligated in FY2011 and FY2012. New authority Medicaid Incentives for the Prevention of Chronic Diseases (MIPCD). Requires the Secretary to award five-year grants to states, subject to annual renewal of funding, to provide incentives for Medicaid beneficiaries to participate in evidence-based healthy lifestyle programs to prevent or help manage chronic disease. Appropriates $100 million for the five-year period beginning January 1, 2011, to remain available until expended. [CMS/CMMI; CFDA 93.536] $30 million CHIP childhood obesity demonstration program. Appropriates $25 million for the period FY2010 through FY2014 for a program authorized by the Children’s Health Insurance Program Reauthorization Act (CHIPRA; P.L. 111-3), which requires the Secretary to conduct a demonstration project to develop a model for reducing childhood obesity. [CDC; CFDA 93.535] $12 million 2801 4108 4306 Amends SSA Sec. 1139A(e) CRS-10 [See http://innovations.cms.gov/initiatives/medicaidemergency-psychiatric-demo/.] [See http://www.macpac.gov/.] [MIPCD grants have been awarded to 10 states. See http://www.innovations.cms.gov/initiatives/MIPCD/ index.html.] [Funding has been awarded to four grantees. See http://www.cdc.gov/obesity/childhood/ researchproject.html.] ACA Section Statutory Authority 10203(d) Amends SSA Secs. 2104 & 2113 Program Obligations as of January 4, 2013, Based on TAGGS Unless Specified Otherwise CHIP annual appropriations, and outreach and enrollment grants. Appropriates funding for the CHIP program for FY2014 ($19.147 billion) and FY2015 ($21.061 billion); the program previously had been funded through FY2013. Also, extends the time period for CHIP outreach and enrollment grants through FY2015 and increases the existing appropriation for such grants from $100 million to $140 million. [CMS; CFDA 93.767] In 2009, and again in 2011, CMS awarded $40 million in two-year grants to states and community organizations. In 2010, CMS awarded $10 million in grants to tribal organizations. [See https://www.cms.gov/apps/media/press/release.asp? Counter=4063.] Medicare 3014 Amends SSA Sec. 1890(b). New SSA Sec. 1890A Medicare quality and efficiency measures. Expands the duties of the consensus-based entity under contract with CMS pursuant to SSA Sec. 1890 (currently the National Quality Forum). Requires the entity to convene multi-stakeholder groups to provide input on the national priorities for health care quality improvement (developed under ACA). In addition, the multi-stakeholder groups are required to provide input on the selection of quality measures for use in various specified Medicare payment systems for hospitals and other providers, as well as in other health care programs, and for use in reporting performance information to the public. Establishes a multi-step pre-rulemaking process and timeline for the adoption, dissemination, and review of measures by the Secretary. Requires the Secretary to transfer from the Medicare Part A and Part B trust funds $20 million for each of FY2010 through FY2014, to remain available until expended.a Total amount = $100 million. [CMS] No public information located on funding obligations. 3021(a) New SSA Sec. 1115A Center for Medicare and Medicaid Innovation (CMMI). Requires the Secretary, no later than January 1, 2011, to establish the CMMI within CMS. The purpose of CMMI is to test and evaluate innovative payment and service delivery models to reduce program expenditures under Medicare, Medicaid, and CHIP while preserving or enhancing the quality of care furnished under these programs. In selecting the models, the Secretary is also required to give preference to those that improve the coordination, quality, and efficiency of health care services. Appropriates (1) $5 million for FY2010 for the selection, testing, and evaluation of new payment and service delivery models; and (2) $10 billion for the period FY2011 through FY2019, plus $10 billion for each subsequent 10-year period, to continue such activities and for the expansion and nationwide implementation of successful models. Amounts are to remain available until expended.b [CMS] According to CMS’s FY2013 budget justification, FY2011 obligations = $95 million; FY2012 obligations (est.) = $1.693 billion; FY2013 obligations (est.) = $1.362 billion. Medicare independence at home demonstration program. Requires the Secretary to conduct a three-year Medicare demonstration program, beginning no later than January 1, 2012, to test a payment incentive and service delivery model that uses physician- and nurse practitioner-directed primary care teams to provide home-based services to chronically ill patients. The Secretary must submit a plan, no later than January 1, 2016, for expanding the program if it is determined that such expansion would improve the quality of care and reduce spending. Requires the Secretary to transfer from the Medicare Part A and Part B trust funds $5 million for each of FY2010 through FY2015 for administering and carrying out the demonstration, to remain available until expended.a Total amount = $30 million. [CMS] No public information located on funding obligations. 3024 New SSA Sec. 1866E CRS-11 [For information on CMMI’s programs, which include several of the initiatives summarized in this table, see http://www.innovations.cms.gov/.] [For a fact sheet on the independence at home demonstration, administered by CMMI, see http://www.innovations.cms.gov/initiatives/Independenceat-Home/index.html.] ACA Section 3026 Statutory Authority New authority Program Obligations as of January 4, 2013, Based on TAGGS Unless Specified Otherwise Community-based care transitions program. Requires the Secretary to establish a five-year program, beginning January 1, 2011, to provide funding to eligible hospitals and community-based organizations that provide evidence-based transition services to Medicare beneficiaries with multiple chronic conditions who are at high risk for hospital readmission. Requires the Secretary to transfer from the Medicare Part A and Part B trust funds $500 million for the period FY2011 through FY2015, to remain available until expended.a [CMS] No public information located on funding obligations. [This program is being administered by CMMI, as part of its Partnership for Patients initiative. See http://www.innovations.cms.gov/initiatives/Partnership-forPatients/index.html.] 3027(b) Amends DRA Sec. 5007 Medicare gainsharing demonstration program. CMS is supporting two projects that allow hospitals to provide gainsharing payments to physicians that represent a share of the savings incurred as a result of collaborative efforts to improve overall quality and efficiency. ACA appropriates $1.6 million for FY2010, to remain available through FY2014 or until expended, for carrying out the demonstration. [CMS] No public information located on funding obligations. 3113 New authority Diagnostic laboratory test demonstration program. Requires the Secretary to conduct a two-year demonstration program beginning July 1, 2011, with a subsequent report to Congress, to test the impact of direct payments for certain complex laboratory tests on Medicare costs and quality of care. Payments are to be made from the Part B trust fund and may not exceed $100 million. Transfers $5 million from the Medicare Part B trust fund, to remain available until expended, for carrying out the demonstration program and preparing the subsequent report. [CMS] Payments under the demonstration began in January 2012. [See http://www.cms.gov/Medicare/DemonstrationProjects/DemoProjectsEvalRpts/Downloads/ TCCDLT_FactSheet.pdf.] 3306 Amends MIPPA Sec. 119 Outreach and assistance for Medicare low-income programs. Transfers a total of $45 million from the Medicare Part A and Part B trust funds for the period FY2010 through FY2012 to extend funding for the following beneficiary outreach and education activities for Medicare low-income programs: (1) State Health Insurance Counseling and Assistance Programs (SHIPs), $15 million; (2) Area Agencies on Aging (AAAs), $15 million; (3) Aging and Disability Resource Centers (ADRCs), $10 million; and (4) the National Center for Benefits Outreach and Enrollment (NCBOE), $5 million. Funds are to remain available until expended.c Note: P.L. 112-240 appropriates $25 million for FY2013 for these programs: (1) SHIPs, $7.5 million; (2) AAAs, $7.5 million; (3) ADRCs, $5 million; and (4) NCBOE, $5 million. [AoA, CMS; CFDA 93.518] HHS announced grant awards totaling $45 million in September 2010. 3403 New SSA Sec. 1899A Independent Payment Advisory Board (IPAB). Creates an independent, 15-member advisory board tasked with presenting Congress with comprehensive proposals to reduce excess cost growth and improve quality of care for Medicare beneficiaries. Appropriates $15 million for FY2012 to support the board’s activities. For each subsequent fiscal year, appropriates the amount from the previous fiscal year adjusted for inflation. Sixty percent of the appropriation is to be derived by transfer from the Medicare Part A trust fund, and 40% is to be derived by transfer from the Medicare Part B trust fund. Note: P.L. 112-74 rescinds $10 million of IPAB’s $15 million appropriation for FY2012; see Appendix C. IPAB members have yet to be appointed. CRS-12 ACA Section Statutory Authority 4202(b) New authority Medicare prevention and wellness evaluation. Transfers $50 million from the Medicare Part A and Part B trust funds, to remain available until expended, to fund an evaluation of community-based prevention and wellness programs and, based on the findings, develop a plan to promote healthy lifestyles and chronic disease self-management among Medicare beneficiaries.a [CMS] No public information located on funding obligations. 4204(e) New authority Medicare vaccine coverage. Appropriates $1 million for FY2010 for a GAO report on the impact of Medicare Part D vaccine coverage on access to those vaccines among beneficiaries. Report released in December 2011 (GAO-12-61). 10323(a) New SSA Sec. 1881A Environmental health hazards. Extends Medicare eligibility to individuals with specified health conditions linked to environmental exposures, who have resided for specified times in an area subject to a Superfund public health emergency declaration. Requires the Secretary to establish a pilot program, with appropriate reimbursement methodologies, to provide comprehensive, coordinated, and cost-effective care to such individuals. Transfers such sums as may be necessary from the Medicare Part A and Part B trust funds to carry out the pilot program.a [CMS] No public information located on funding obligations. 10323(b) New SSA Sec. 2009 Environmental health hazards. Appropriates $23 million for the period FY2010 through FY2014, and $20 million for each five-year period thereafter, for grants to state and local government agencies, health care facilities, and other entities to (1) provide screening for specified lung diseases and other environmental health conditions to individuals who have resided for specified times in an area subject to a Superfund public health emergency declaration; and (2) disseminate public information about the availability of screening, the detection and treatment of environmental health conditions, and the availability of Medicare benefits to certain individuals diagnosed with such conditions, pursuant to new SSA Sec. 1881A (as added by ACA Sec. 10323(a)). [CMS; CFDA 93.534] $5 million Health Care Fraud and Abuse Control (HCFAC) Account. Applies a permanent inflation adjustment to the annual appropriation (provided under SSA Sec. 1817(k)) for the HCFAC account. Appropriates from the Medicare Part A trust fund the following supplemental amounts for the HCFAC account: $10 million for each of FY2011 through FY2020; plus an additional $95 million for FY2011, $55 million for FY2012, $30 million for each of FY2013 and FY2014, and $20 million for each of FY2015 and FY2016. Funds are to remain available until expended. Total amount = $350 million. [CMS] No public information located on funding obligations. Program Obligations as of January 4, 2013, Based on TAGGS Unless Specified Otherwise [Funding provided for an asbestos health screening program in Libby, Montana.] Fraud and Abuse 6402(i) & HCERA Sec. 1303(a) Amends SSA Sec. 1817(k) Health Centers and the National Health Service Corps 4101(a) CRS-13 New authority School-based health centers (SBHCs). Appropriates $50 million for each of FY2010 through FY2013, to remain available until expended, for a grant program to fund the construction and renovation of school-based health centers. Total amount = $200 million. [HRSA; CFDA 93.501] $142 million [In December 2012, HRSA announced a third round of awards to SBHCs totaling $80 million. See http://bphc.hrsa.gov/about/schoolbased/index.html.] ACA Section 10503(b)(1) Statutory Authority New authority Program Obligations as of January 4, 2013, Based on TAGGS Unless Specified Otherwise Community Health Center Fund (CHCF). Transfers from the CHCF the following amounts for health center operations, to remain available until expended: FY2011 = $1 billion; FY2012 = $1.2 billion; FY2013 = $1.5 billion; FY2014 = $2.2 billion; and FY2015 = $3.6 billion. Total amount = $9.5 billion. [HRSA; CFDA 93.527] In FY2011 and FY2012, HRSA awarded a total of approximately $1.1 billion in ACA grants to support health center operations and related activities. [See http://bphc.hrsa.gov/about/healthcenterfactsheet.pdf.] 10503(b)(2) New authority National Health Service Corps (NHSC). Transfers from the CHCF the following amounts for NHSC operations, scholarships, and loan repayments, to remain available until expended: FY2011 = $290 million; FY2012 = $295 million; FY2013 = $300 million; FY2014 = $305 million; and FY2015 = $310 million. Total amount = $1.5 billion. [HRSA; CFDA 93.547] According to the President’s FY2013 budget, obligations are as follows: FY2011 = $289 million; FY2012 (est.) = $296 million; FY2013 (est.) = $300 million. 10503(c) New authority Health center construction and renovation. Appropriates $1.5 billion, to be available for the period FY2011 through FY2015, and to remain available until expended, for health center construction and renovation. [HRSA; CFDA 93.526] $1.509 billion Health workforce demonstration programs. Requires the Secretary to establish two demonstration projects. The first is to award health profession opportunity grants to states, Indian tribes, institutions of higher education, and local workforce investment boards to help low-income individuals obtain education and training in health care jobs that pay well and are in high demand. Funds may be used to provide financial aid and other supportive services. The second project is to provide states with grants to develop core training competencies and certification programs for personal and home care aides. Appropriates $85 million for each of FY2010 through FY2014, of which $5 million in each of FY2010 through FY2012 is to be used for the second project. Total amount = $425 million. [ACF, HRSA; CFDA 93.093, 93.512] $195 million: Health Profession Opportunity Grant (HPOG) Amends SSA Sec. 501(c) Family-to-family health information centers. Renews funding for the family-to-family information centers, which assist families of children with disabilities or special health care needs and the professionals who serve them, by appropriating $5 million for each of FY2010 through FY2012, to remain available until expended. Total amount = $15 million. Note: P.L. 112-240 appropriates $5 million for FY2013. [HRSA; CFDA 93.504] $5 million (FY2012) New PHSA Sec. 340H Teaching health centers. Appropriates such sums as may be necessary, not to exceed $230 million, for the period FY2011 through FY2015 to make payments for direct and indirect graduate medical education (GME) costs to qualified teaching health centers (THCs). [HRSA; CFDA 93.530] $30 million New authority Medicare graduate nurse education demonstration program. Appropriates $50 million for each of FY2012 through FY2015, to remain available until expended, for a Medicare demonstration program under which up to five eligible hospitals will receive reimbursement for providing advanced practice nurses with clinical training in primary care, preventive care, transitional care, and chronic care management. Total amount = $200 million. [CMS/CMMI] CMMI, which is administering this program, has selected the five participating hospitals and begun making reimbursement payments. Health Workforce 5507(a) 5507(b) 5508(c) 5509 CRS-14 New SSA Sec. 2008 $13 million: Personal and Home Care Aide State Training (PHCAST) program [See http://www.acf.hhs.gov/programs/ofa/programs/hpog and http://bhpr.hrsa.gov/nursing/grants/phcast.html.] [See http://mchb.hrsa.gov/programs/familytofamily/ index.html.] [See http://bhpr.hrsa.gov/grants/teachinghealthcenters/.] [See http://innovations.cms.gov/initiatives/GNE/index.html.] ACA Section 10502 Statutory Authority New authority Program Health care facility construction. Appropriates $100 million for FY2010, to remain available for obligation until Sept. 30, 2011, for debt service on, or construction or renovation of, a hospital affiliated with a state’s sole public medical and dental school. [HRSA; CFDA 93.502] Obligations as of January 4, 2013, Based on TAGGS Unless Specified Otherwise $100 million [Funding awarded to Ohio State University.] Community-Based Prevention and Wellness 4002 New authority Prevention and Public Health Fund (PPHF). Establishes a PPHF and originally provided a permanent annual appropriation to the fund, as follows: FY2010 = $500 million; FY2011 = $750 million; FY2012 = $1 billion; FY2013 = $1.25 billion; FY2014 = $1.5 billion; FY2015 and each year thereafter = $2 billion. Requires the Secretary to transfer amounts from the fund to HHS accounts to increase funding, over the FY2008 level, for PHSAauthorized prevention, wellness, and public health activities, including prevention research and health screenings. Authorizes House and Senate appropriators to transfer monies from the PPHF to eligible activities. Note: P.L. 112-96 subsequently reduced the annual appropriations to the PPHF over the period FY2013-FY2021, as follows: FY2013 through FY2017 = $1 billion; FY2018 and FY2019 = $1.25 billion; FY2020 and FY2021 = $1.5 billion; FY2022 and each year thereafter = $2 billion. [OS, CDC, HRSA, SAMHSA, ACL; CFDA 93.507, 93.521, 93.522, 93.523, 93.524, 93.531, 93.533, 93.538, 93.539, 93.540, 93.542.] PPHF funds are annual appropriations that must be obligated during the fiscal year in which they are made available. For a complete list of all PPHF obligations for FY2010 and FY2011, see the GAO report, Prevention and Public Health Fund: Activities Funded in Fiscal Years 2010 and 2011 (GAO-12-788), at http://www.gao.gov/assets/650/ 648310.pdf. For a summary of the activities and programs, by agency, that were supported with FY2012 PPHF funds, see http://www.hhs.gov/open/recordsandreports/prevention/ index.html. [This website was mandated by P.L. 112-74; see Appendix C.] Note: The listed CFDA programs do not capture all the uses of PPHF funding. PPHF funds have also been integrated into existing programs that do not mention PPHF. Maternal and Child Health 2951 2953 CRS-15 New SSA Sec. 511 Maternal, infant, and early childhood home visiting program. Appropriates the following amounts for grants to states, U.S. territories, and Indian tribes to develop and implement early childhood home visiting programs that adhere to evidence-based models of service delivery: FY2010 = $100 million; FY2011 = $250 million, FY2012 = $350 million; FY2013 = $400 million; FY2014 = $400 million. Total amount = $1.5 billion. Programs must establish benchmarks to measure improvements for the participating families in maternal and newborn health; prevention of child abuse or neglect or child injuries; school readiness and achievement; reductions in crime or domestic violence; family economic self-sufficiency; and coordination and referrals for other community resources and supports. [HRSA, ACF; CFDA 93.505, 93.508] $639 million New SSA Sec. 513 Personal Responsibility Education Program (PREP). Establishes a state formula grant program to support evidence-based PREPs designed to educate adolescents about abstinence, contraception, and adulthood. Also, requires the Secretary to award grants to implement innovative youth pregnancy prevention strategies and to target services at highrisk populations. Appropriates $75 million for each of FY2010 through FY2014, of which $10 million each year is to be reserved for the youth pregnancy prevention grants. Funds are to remain available until expended. Total amount = $375 million. [ACF; CFDA 93.092] $215 million [See http://mchb.hrsa.gov/programs/homevisiting/.] [See http://www.acf.hhs.gov/programs/fysb/programs/ adolescent-pregnancy-prevention/programs/prepcompetitive.] ACA Section 2954 1021110214 Statutory Authority Program Obligations as of January 4, 2013, Based on TAGGS Unless Specified Otherwise Amends SSA Sec. 510 Abstinence education grants. Renews funding for the state formula grant program to support abstinence education programs by appropriating $50 million for each of FY2010 through FY2014. Total amount = $250 million. Funds are awarded to states based on the proportion of low-income children in each state compared to the national total, and may only be used for teaching abstinence. [ACF, CDC; CFDA 93.235] $83 million (FY2010-FY2012) New authority Pregnancy assistance grants. Appropriates $25 million for each of FY2010 through FY2019 (total amount = $250 million) to establish a Pregnancy Assistance Fund for the purpose of awarding grants to states to assist pregnant and parenting teens and women. State grantees have the flexibility to make funds available to institutions of higher education, high schools and community service centers, and to the state attorneys general to improve services for pregnant women who are victims of domestic violence, sexual assault, or stalking. [OS; CFDA 93.500] $72 million Amends DRA Sec. 6071(h) Medicaid Money Follows the Person (MFP) demonstration program. Extends funding for the MFP demonstration through FY2016. The program authorizes the Secretary to award competitive grants to states to reduce their reliance on institutional care for people needing long-term care, and expand options for elderly people and individuals with disabilities to receive home and community-based long-term care services. Appropriates $450 million for each of FY2012 through FY2016, to remain available through FY2016. Total amount = $2.25 billion. [CMS; CFDA 93.791] $293 million (FY2012 only) New authority State Aging and Disability Resource Centers (ADRCs). Appropriates $10 million for each of FY2010 through FY2014 (total amount = $50 million) for ADRCs, authorized under OAA Sec. 202. ADRCs serve as a single, coordinated resource for consumer information on the range of long-term care options in community and institutional settings. Some ADRCs also serve as the entry point to publicly administered long-term care programs (e.g., Medicaid, OAA services, state assistance programs). AoA and CMS have invested more than $100 million in the ADRC program since 2003. ADRCs currently operate in over 350 community sites across 54 states and territories. See also the entry for ACA Sec. 3306, above. [AoA; CFDA 93.517] $15 million Background checks of long-term care providers. Requires the Secretary to establish a nationwide program for background checks on direct patient access employees of longterm care facilities or providers, and to provide federal matching funds to states to conduct these activities. Requires the Treasury Secretary to transfer to HHS an amount, not to exceed $160 million, that is specified by the HHS Secretary as necessary to carry out the program for the period FY2010 through FY2012. Funds are to remain available until expended. [CMS; CFDA 93.506] $48 million [See http://www.acf.hhs.gov/programs/fysb/resource/aegpfact-sheet.] [See http://www.hhs.gov/ash/oah/oah-initiatives/paf/ home.html.] Long-Term Care 2403 2405 6201 New authority CRS-16 [See http://www.medicaid.gov/Medicaid-CHIP-ProgramInformation/By-Topics/Long-Term-Services-and-Support/ Balancing/Money-Follows-the-Person.html.] [See http://www.aoa.gov/AoA_programs/HCLTC/ADRC/ index.aspx.] ACA Section Statutory Authority 8002(d) Amends DRA Sec. 6021(d) Program National Clearinghouse for Long-Term Care Information. Appropriates $3 million for each of FY2011 through FY2015 for the National Clearinghouse for Long-Term Care Information, and requires the Clearinghouse to include information on the Community Living Assistance Services and Supports (CLASS) program, established under ACA Sec. 8002(a). Total amount = $15 million. [AoA] Obligations as of January 4, 2013, Based on TAGGS Unless Specified Otherwise No public information located on funding obligations. However, these are annual appropriations that must be obligated during the fiscal year in which they are made available. [See http://www.longtermcare.gov/LTC/Main_Site/ index.aspx.] Comparative Effectiveness Research 6301(d)-(e) New IRC Secs. 9511, 4375, & 4376. New SSA Sec. 1183 Patient-Centered Outcomes Research Trust Fund (PCORTF). Establishes a PCORTF to fund the new Patient-Centered Outcomes Research Institute (PCORI) and its comparative effectiveness research activities. Appropriates to the PCORTF $10 million for FY2010, $50 million for FY2011, and $150 million for each of FY2012 through FY2019, for a total of $1.26 billion over that 10-year period. For each of FY2013 through FY2019, the PCORTF is to receive additional appropriations equal to the net revenues from a new health insurance policy/plan fee,d as well as Medicare trust fund transfers.e Each fiscal year, 20% of the funds in the PCORTF are to be transferred to the Secretary, to remain available until expended. Of those transferred funds, 80% are to be provided to AHRQ. [OS, AHRQ] In June 2012, PCORI announced pilot project grant awards totaling $30 million over two years. In December 2012, PCORI announced its first comparative effectiveness research grant awards totaling $41 million over three years. Therapeutic research and development tax credits and grants. Creates a two-year tax credit program, subject to an overall cap of $1 billion, for small companies (250 or fewer employees) that invest in new therapies to prevent, diagnose, and treat cancer and other diseases. Companies may apply for one or more tax credits, each covering up to 50% of the cost of qualifying research investments made in 2009 and 2010. However, the total amount of tax credits any one company receives for the two years may not exceed $5 million. Companies may elect to receive one or more grants in lieu of tax credits, subject to the same restrictions (i.e., grants may cover up to 50% of the cost of qualifying investments made in 2009 and 2010; the total amount of grants any one company receives for the two years may not exceed $5 million). Appropriates such sums as may be necessary to carry out the grant program. [IRS] According to the IRS: total grant awards = $970 million; total tax credits = $17 million. [See http://www.pcori.org/.] Biomedical Research 9023 New IRC Sec. 48D [See http://www.irs.gov/Businesses/Small-Businesses-&-SelfEmployed/Qualifying-Therapeutic-Discovery-ProjectCredits-and-Grants.] ACA Implementation: Administrative Expenses HCERA Sec. 1005 New authority Health Insurance Reform Implementation Fund (HIRIF). Appropriates $1 billion to the HIRIF for federal administrative expenses to carry out ACA. [OS; CFDA 93.528] The HIRIF funds were projected to have all been obligated by the end of FY2012. Source: Prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148), as amended. a. Transfers from the two trust funds are in such proportion as the Secretary determines appropriate. b. Of the amounts appropriated for the period FY2011-FY2019, and for each subsequent 10-year period, at least $25 million must be made available each fiscal year for the selection, testing, and evaluation of new payment and service delivery models. CRS-17 c. Transfers from the two trust funds are in the same proportion as the Secretary determines under SSA Sec. 1853(f). d. The health insurance fee is to equal $2 multiplied by the average number of covered lives in a policy/plan year ($1 in the case of a policy/plan year ending during FY2013), updated annually by the rate of medical inflation beginning in FY2015. e. The trust fund transfers are to equal $2 ($1 in FY2013) multiplied by the average number of individuals entitled to benefits under Part A or enrolled under Part B in a given fiscal year, updated annually by the rate of medical inflation beginning in FY2015. CRS-18 Table 2. ACA Appropriations and Fund Transfers by Fiscal Year FY2010-FY2019 Appropriation (or Fund Transfer) in $ millions ACA Section Program FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 FY2016 FY2017 FY2018 FY2019 Totala Private Health Insurance 1002 Health insurance consumer information 30b 1003 Review of health insurance premium rates 250 — — — — — — — — — 250 1101 Temporary high-risk health insurance pools 5,000b — — — — — — — — — 5,000 1102 Early retiree reinsurance program 5,000b — — — — — — — — — 5,000 1311 Health insurance exchange planning and establishment Appropriates amounts necessary for grants each fiscal year, as determined by the Secretary; no grant awards after Jan. 1, 2015 — — — — TBDc 1322 Consumer operated and oriented plans (CO-OPs) 6,000d — — — — — — — 6,000 1323 Health insurance exchange subsides (U.S. territories) — — — — (Note: This section also authorizes to be appropriated SSAN for FY2011 and each fiscal year thereafter.) — — $1 billion total for CY2014 through CY2109e 30 1,000 Medicaid and Children’s Health Insurance Program (CHIP) 2701 Medicaid adult health quality measures 60 60 60 60 60 — — — — — 300f 2707 Medicaid emergency psychiatric demonstration — 75g — — — — — — — — 75 2801 Medicaid and CHIP Payment and Access Commission 4108 Medicaid prevention and wellness incentives — 4306 CHIP childhood obesity demonstration $25 million total for FY2010 through FY2014 10203(d) CHIP annual appropriationi — 10203(d) CHIP outreach and enrollment grants CRS-19 11h (Note: This section also authorizes to be appropriated SSAN for FY2011 and each fiscal year thereafter.) $100 million total for CY2011 through CY2015f 11 — — — — 100 — — — — — 25 21,061 — — — — 40,208 Increases total funding from $100 million to $140 million and extends funding period through FY2015 — — — — 40 — — — 19,147 Appropriation (or Fund Transfer) in $ millions ACA Section Program FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 FY2016 FY2017 FY2018 20j 20 20 20 20 — — — — FY2019 Totala Medicare 3014 Medicare quality and efficiency measures 3021(a) Center for Medicare and Medicaid Innovation 5 3024 Medicare independence at home demonstration 5j 3026 Community-based care transition services 3027(b) Medicare gainsharing demonstration 3113 Diagnostic laboratory test demonstration 3306 Outreach and assistance for low-income beneficiaries 3403 Independent Payment Advisory Board — — 5m 4202(b) Prevention and wellness evaluation 50j — — — — — — — — — 50 4204(e) GAO study of Medicare vaccine coverage 1 — — — — — — — — — 1 10323(a) Environmental health pilot program 10323(b) Environmental health screening and education — — plus $10 billion total for FY2011 through FY2019, and $10 billion for each subsequent 10-year period 5 5 5 5 5 $500 million total for FY2011 through FY2015j 100 10,005f — — — — 30 — — — — 500 2 — — — — — — — — — 2f 5k — — — — — — — — — 5 25l — — — — — — 70 For FY2013 and each subsequent fiscal year, appropriates previous year’s amount adjusted for inflation; funds derived from the Medicare trust funds. TBDc $45 million total for FY2010 through FY2012l SSANj TBDc $20 million total for FY2015 though FY2019, and for each 5-year period thereafter $23 million total for FY2010 through FY2014 43f Fraud and Abuse 6402(i) & HCERA 1303(a) Health Care Fraud and Abuse Control (HCFAC) Account — 105 65 40 40 30 30 10 10 10 350n 50 50 — — — — — — 200f Health Centers and the National Health Service Corps (NHSC) 4101(a) CRS-20 School-based health center establishment grants 50 50 Appropriation (or Fund Transfer) in $ millions ACA Section Program FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 FY2016 FY2017 FY2018 FY2019 Totala 10503(b)(1) Community Health Centers Fund, patient services — 1,000 1,200 1,500 2,200 3,600 — — — — 9,500f 10503(b)(2) Community Health Centers Fund, NHSC — 290 295 300 305 310 — — — — 1,500f 10503(c) Community health center construction and renovation — $1.5 billion total for FY2011 through FY2015 — — — — 1,500f Health Workforce 5507(a) Health workforce demonstration grants 85 85 85 85 85 — — — — — 425 5507(b) Family-to-family health information centers 5 5 5 5o — — — — — — 20f 5508(c) Teaching health centers, GME payments — SSAN for FY2011 through FY2015, not to exceed $230 million — — — — ≤230 5509 Medicare graduate nurse education demonstration — — 50 50 50 50 — — — — 200f 10502 Health care facility construction 100 — — — — — — — — — 100p 500 750 1,000 1,000 1,000 1,000 1,000 1,000 1,250 1,250 9,750q Community-Based Prevention and Wellness 4002 Prevention and Public Health Fund Maternal and Child Health 2951 Maternal, infant, and early childhood home visitation 100 250 350 400 400 — — — — — 1,500 2953 Personal responsibility education program grants 75 75 75 75 75 — — — — — 375f 2954 Abstinence education state grants 50 50 50 50 50 — — — — — 250 10214 Pregnancy assistance grants 25 25 25 25 25 25 25 25 25 25 250 — 450 450 450 450 450 450 — — — 2,700 Long-Term Care 2403 CRS-21 Medicaid money follows the person demonstration Appropriation (or Fund Transfer) in $ millions ACA Section Program 2405 State Aging and Disability Resource Centers 6201 Background checks of longterm care providers 8002(d) National Clearinghouse for Long-Term Care Information FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 FY2016 FY2017 FY2018 10 10 10 10 10 — — — — — 50 — — — — — — — ≤160r 3 3 3 — — — — 15 Up to $160 million total for FY2010 through FY2012 FY2019 Totala — 3 3 Patient-Centered Outcomes Research Trust Fund, Medicare transfers — — — For each of FY2013-FY2019, transfers amounts from the Medicare trust funds as determined by a formula TBDs Patient-Centered Outcomes Research Trust Fund, appropriations 10 50 150 For each of FY2013-FY2019, appropriates $150 million plus an amount equal to the net revenue from a fee levied on insurance policies and health plans TBDt SSAN — — — — — — — — — ≤1u 1,000 — — — — — — — — — 1,000 Comparative Effectiveness Research 6301(d) 6301(e) Biomedical Research 9023(e) Grants for investment in new therapeutics PPACA Implementation HCERA 1005 Health Insurance Reform Implementation Fund Source: Prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148), as amended. Notes: Funds are provided from the Treasury unless otherwise noted. A dash means that ACA does not appropriate or transfer funds for the fiscal year(s) noted. a. Total represents the cumulative amount of appropriations or fund transfers over the 10-year period FY2010-FY2019. Note that in several instances the 10-year total is yet to be determined (TBD); see table entries for ACA Secs. 1311, 3403, 6301(d) & (e), 9023(e), and 10323(a). In addition, four provisions provide annual or multipleyear appropriations beyond FY2019. The total shown in the table for three of these provisions represents the cumulative amount appropriated through FY2019; see table entries for ACA Secs. 3021(a), 4002 (discussed in table note “q” below), and 10323(b). Finally, the total for ACA Sec. 6402(i) includes an amount appropriated in FY2020 (see table note “n” below). b. Funds are to remain available without fiscal year limitation. c. To be determined. d. ACA Sec. 1322 appropriated $6 billion for the CO-OP program. Subsequently, Division B, Title VIII, Sec. 1857 of P.L. 112-10 canceled $2.2 billion of that appropriation; Division F, Title V, Sec. 524 of P.L. 112-74 rescinded an additional $400 million; and Sec. 644 of P.L. 112-240 rescinded all but 10% of the remaining unobligated funds. See Appendix C. e. Of this total amount, $925 million is for Puerto Rico, and the remaining $75 million is for the other U.S. territories in amounts as specified by the Secretary. CRS-22 f. Funds are to remain available until expended. g. Funds are to remain available for obligation through Dec. 31, 2015. h. Of this total amount, $9 million is appropriated, and the remaining $2 million is a transfer from CHIP funding for FY2010. Funds are to remain available until expended. i. Prior to enactment of ACA, the CHIP program was funded through FY2013. j. The Secretary is required to transfer amounts from the Medicare Part A and Part B trust funds each fiscal year in such proportion as the Secretary determines appropriate. Funds are to remain available until expended. k. The Secretary is required to transfer the $5 million from the Medicare Part B trust fund, to remain available until expended. l. The Secretary is required to transfer amounts from the Medicare Part A and Part B trust funds in the same proportion as the Secretary determines under SSA Sec. 1853(f). Funds are to remain available until expended. Note: Sec. 610 of P.L. 112-240 appropriated $25 million for FY2013 for the four outreach and assistance programs funded under ACA Sec. 3306. See Table 1 and Appendix C. m. Division F, Title V, Sec. 525 of P.L. 112-74 rescinded $10 million of IPAB’s appropriation for FY2012. See Appendix C. n. Funds are to be appropriated from the Medicare Part A trust fund. Note: the total amount appropriated (i.e., $350 million) includes a final appropriation of $10 million for FY2020. o. Sec. 624 of P.L. 112-240 appropriated $5 million for FY2013 for this program. p. Funds are to remain available for obligation until Sept. 30, 2011. q. ACA Sec. 4002 originally provided a permanent annual appropriation to the Prevention and Public Health Fund, as follows: FY2010 = $500 million; FY2011 = $750 million; FY2012 = $1 billion; FY2013 = $1.25 billion; FY2014 = $1.5 billion; FY2015 and each year thereafter = $2 billion. Subsequently, P.L. 112-96 reduced the annual appropriations to the PPHF over the period FY2013-FY2021, as follows: FY2013 through FY2017 = $1 billion; FY2018 and FY2019 = $1.25 billion; FY2020 and FY2021 = $1.5 billion; FY2022 and each year thereafter = $2 billion. Thus, appropriations to the fund now total $9.750 billion over the period FY2010-FY2019. r. The HHS Secretary is required to notify the Treasury Secretary of the amount necessary to carry out activities under this section for the period of FY2010 through FY2012, but not to exceed $160 million. The Treasury Secretary must then transfer the amount specified from the Treasury to the HHS Secretary. Funds are to remain available until expended. s. To be determined. ACA Sec. 6301(d) provided the following formula for the transfer of funds from the Medicare Part A and Part B trust funds to the Patient-Centered Outcomes Research Trust Fund: (1) for FY2013, an amount from each respective Medicare trust fund equal to $1 multiplied by the average number of individuals entitled to Part A benefits, or enrolled in Part B during that period; and (2) for each of FY2014-FY2019, an amount from each respective Medicare trust fund equal to $2 multiplied by the average number of individuals entitled to Part A benefits, or enrolled in Part B during that fiscal year. Beginning in FY2015, amounts are subject to adjustment for increases in health care spending. t. To be determined. In addition to the amounts transferred to the Patient-Centered Outcomes Research Trust Fund under ACA Sec. 6301(d), described in the preceding table note, ACA Sec. 6301(e) appropriated to the Fund a specified amount for each of FY2010-FY2019, plus an additional amount for each of FY2013 through FY2019 equal to the net revenues received from a fee imposed on health insurance policies and self-insured plans. The fee equals $2 multiplied by the average number of covered lives in a policy/plan year ($1 in the case of policy/plan years ending during FY2013). Beginning in FY2015, amounts are subject to adjustment for increases in health care spending. u. To be determined. ACA Sec. 9023(e) created a two-year tax credit program, subject to an overall cap of $1 billion, for small companies that invest in new therapies to prevent, diagnose and treat cancer and other diseases. The total amount of tax credits any one company can receive for the two years may not exceed $5 million. Companies may elect to receive one or more grants—for which SSAN are appropriated—in lieu of tax credits. Grant applications must be received before Jan. 1, 2013. CRS-23 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act Appendix A. Acronyms Used in the Report The following laws and federal agencies are referred to in this report by their acronym: AoA Administration on Aging ACF Administration for Children and Families AHRQ Agency for Healthcare Research and Quality BBEDCA Balanced Budget and Emergency Deficit Control Act of 1985 (P.L. 99-177) CCIIO Center for Consumer Information and Insurance Oversight CDC Centers for Disease Control and Prevention CHIP Children’s Health Insurance Program CMS Centers for Medicare & Medicaid Services DRA Deficit Reduction Act of 2005 (P.L. 109-171) HCERA Health Care and Education Reconciliation Act of 2010 (P.L. 111-152) HRSA Health Resources and Services Administration OS HHS Office of the Secretary IRC Internal Revenue Code IRS Internal Revenue Service MIPPA Medicare Improvements for Patients and Providers Act of 2008 (P.L. 110-275) OAA Older Americans Act PHSA Public Health Service Act PPACA Patient Protection and Affordable Care Act (P.L. 111-148) SSA Social Security Act Congressional Research Service 24 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act Appendix B. ACA-Related Authorizing Legislation in the 112th Congress Lawmakers opposed to specific provisions in ACA, or to the entire law, introduced numerous bills in the 112th Congress to modify or repeal the law. Most of the legislative activity on these bills took place in the House. The ACA-related legislation included bills that would have (1) repealed the law in its entirety and, in some instances, replaced it with new law; (2) repealed or amended specific provisions in the law; (3) eliminated certain mandatory appropriations in ACA (discussed in this report) and rescinded all unobligated funds;19 (4) replaced the mandatory appropriations for one or more ACA programs with authorizations of appropriations, and rescinded all unobligated funds; and (5) blocked or otherwise delayed ACA implementation. A few provisions, with sufficiently broad and bipartisan support were approved in both the House and the Senate and signed into law. This appendix summarizes the ACA-related provisions in authorization legislation enacted during the 112th Congress. It also provides a brief overview of each of the ACA-related bills that were passed by the House, but which were not approved by the Senate. Appendix C summarizes the ACA-related provisions in annual appropriations acts for the period FY2011-FY2013. Enacted Legislation P.L. 112-9 (April 14, 2011; H.R. 4), Comprehensive 1099 Taxpayer Protection and Repayment of Exchange Subsidy Overpayments Act of 2011. P.L. 112-9 repealed the ACA requirement that businesses file an information report (IRS Form 1099) whenever they pay a vendor more than $600 for goods in a single year. To pay for the 1099 repeal, P.L. 112-9 raised the limits on the amount of excess premium tax credits that individuals would have to repay. [Note: Under ACA, the amount received in premium credits is based on income as reported on tax returns. These amounts are reconciled the following year, which could result in an overpayment of credits if income increases. ACA placed limits on the amount of any premium credit overpayment that had to be repaid to the government.] P.L. 112-56 (November 21, 2011; H.R. 674), 3% Withholding Repeal and Job Creation Act. Among its many provisions, P.L. 112-56 amended the calculation of Modified Adjusted Gross Income (MAGI) to include Social Security benefits. MAGI will be used to determine eligibility for health insurance exchange subsidies and Medicaid, beginning in 2014. P.L. 112-96 (February 22, 2012; H.R. 3060), Middle Class Tax Relief and Job Creation Act of 2012. Among its many provisions, P.L. 112-96: (1) reduced ACA’s annual appropriations to the PPHF over the period FY2013-FY2021 by a total of $6.25 billion to help offset the costs of the law’s extension of the payroll tax cut; (2) extended by one year the disproportionate share hospital (DSH) allotment reduction imposed by ACA; and (3) corrected the formula to phase down ACA’s Medicaid disaster-recovery FMAP adjustment as originally intended. [Note: The purpose of the adjustment was to help Louisiana avoid a significant reduction in its federal Medicaid match (i.e., Federal Medical Assistance Percentage, or FMAP) in the aftermath of 19 Of the total amount of funding available for obligation, the unobligated balance represents the funds that an agency has not yet awarded or otherwise made a legal commitment to provide as payment for goods or services. Congressional Research Service 25 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act Hurricane Katrina. As written in ACA, the formula for the disaster-recovery FMAP adjustment unintentionally caused the FMAP adjustment to increase, rather than phase down, each year the state qualifies for the adjustment.] P.L. 112-141 (July 6, 2012; H.R. 4348), Moving Ahead for Progress in the 21st Century Act, or “MAP-21”. Among its many provisions, P.L. 112-141 included a further adjustment to ACA’s Medicaid disaster-recovery provision (see entry for P.L. 112-96, above). P.L. 112-240 (January 2, 2013; H.R. 8), American Taxpayer Relief Act of 2012. Among its many provisions, P.L. 112-240: (1) provided $25 million for FY2013 for the four outreach and assistance programs that were funded by ACA Sec. 3306 through FY2012; (2) provided $5 million for FY2013 for the family-to-family information centers, which ACA Sec. 5507(b) funded through FY2012; and (3) repealed the Community Living Assistance Services and Supports (CLASS) program. House-passed Bills H.R. 2, Repealing the Job-Killing Health Care Law Act. Passed the House by a vote of 245189 on January 19, 2011; offered as an amendment during Senate floor debate on an unrelated bill (S. 223) and rejected on a procedural motion by a vote of 47-51. H.R. 2 would have repealed ACA in its entirety and restored the provisions of law amended or repealed by ACA as if it had not been enacted. H.R. 5, Protecting Access to Healthcare Act. Passed the House by a vote of 223-181 on March 22, 2012. Title II of H.R. 5 would have repealed the authority and appropriations for the Independent Payment Advisory Board (IPAB). H.R. 358, Protect Life Act. Passed the House by a vote of 251-172 on October 13, 2011. H.R. 358 would have prohibited using any funds authorized or appropriated by ACA to pay for an abortion or to pay for any part of the costs of a health plan that covers abortions, except if the pregnancy is the result of rape or incest, or the life of the pregnant female is at risk unless an abortion is performed. It would have required insurers that offer plans through the exchanges that cover abortion services to offer identical plans that do not cover abortion services. It also would have prohibited federal, state or local government programs that receive ACA funding from discriminating against health care entities that refuse to provide abortion services or abortion training. H.R. 436, Health Care Cost Reduction Act of 2012. Passed the House by a vote of 270-146 on June 7, 2012. H.R. 436 would have (1) repealed ACA’s 2.3% excise tax on medical devices; (2) repealed the law’s restrictions on using tax-preferred accounts to pay for over-the-counter drugs; (3) allowed individuals to recoup up to $500 of unused funds remaining in their flexible spending account (FSA) after the end of the plan year; and (4) eliminated all limits on repayment of any premium credit overpayment, making individuals liable for the full amount. H.R. 1173, Fiscal Responsibility and Retirement Security Act of 2012. Passed the House by a vote of 267-159 on February 1, 2012. H.R. 1173 would have repealed the Community Living Assistance Services and Supports (CLASS) program. H.R. 1213, A bill to repeal ACA funding for health insurance exchanges. Passed the House by a vote of 238-183 on May 3, 2011. H.R. 1213 would have repealed the authority and Congressional Research Service 26 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act appropriations for state exchange planning and establishment grants and rescinded all unobligated funds. H.R. 1214, A bill to repeal ACA funding for school-based health center (SBHC) construction. Passed the House by a vote of 235-191 on May 4, 2011. H.R. 1214 would have repealed the authority and appropriations for SBHC construction grants and rescinded all unobligated funds. H.R. 1216, A bill to convert funding for graduate medical education (GME) in qualified teaching health centers (THCs) to an authorization of appropriations. Passed the House by a vote of 234-185 on May 25, 2011. H.R. 1216 would have replaced the appropriation for GME payments to THCs with an authorization of appropriations for each of FY2012 through FY2015, and rescinded all unobligated funds. It would have prohibited the GME funds from being used to provide abortions, except in cases of rape or incest or when the woman’s life is in danger. H.R. 1217, A bill to repeal the Prevention and Public Health Fund (PPHF). Passed the House by a vote of 236-183 on April 13, 2011. H.R. 1217 would have repealed the authority and appropriations for the PPHF and rescinded all unobligated funds. H.R. 4628, Interest Rate Reduction Act. Passed the House by a vote of 215-195 on April 27, 2012. H.R. 4628 would have postponed by one year a scheduled increase in Stafford education loan rates and, to offset the costs of that adjustment, repealed the authority and appropriations for the PPHF and rescinded all unobligated funds. [Note: The one-year Stafford loan rate extension was incorporated as Division F, Title III of MAP-21, the surface transportation reauthorization bill (see entry for P.L. 112-141, above). The provision in H.R. 4628 to repeal PPHF and rescind all unobligated funds was not included in MAP-21.] H.R. 5652, Sequester Replacement Reconciliation Act of 2012. Passed the House by a vote of 218-199 on May 10, 2012. H.R. 5652, which was introduced pursuant to the reconciliation instructions in the House FY2013 budget resolution (H.Con.Res. 112), would have replaced the FY2013 sequestration of discretionary spending (as required under the Budget Control Act of 2011) with a $19 billion reduction in the FY2013 discretionary cap, and would have implemented a series of mandatory program savings recommended by six House committees. Among its many provisions, H.R. 5652 would have (1) eliminated all limits on repayment of any premium credit overpayment, making individuals liable for the full amount; (2) repealed the authority and appropriations for the exchange planning and establishment grants and rescinded all unobligated funds; (3) repealed the authority and appropriations for the PPHF and rescinded all unobligated funds; (4) rescinded all remaining unobligated funds for the Consumer Operated and Oriented Plan (CO-OP) program; (5) extended by one year the DSH allotment reduction imposed by ACA; and (6) repealed ACA’s Medicaid maintenance of effort requirements. H.R. 6079, Repeal of Obamacare Act. Passed the House by a vote of 244-185 on July 11, 2012. H.R. 6079 would have repealed all of ACA, except the authority for IPAB (see entry for H.R. 5, above), and restored the provisions of law amended or repealed by ACA as if it had not been enacted. Congressional Research Service 27 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act Appendix C. ACA Provisions in Appropriations Bills (FY2011-FY2013) Numerous ACA-related provisions have been included in appropriations legislation introduced and enacted since passage of the health reform law. These provisions, often referred to as appropriations riders, generally are of two types: (1) appropriations restrictions that prohibit the use of discretionary funds provided in the bill to implement specific ACA provisions or the entire law; and (2) legislative language that amends or repeals specific ACA provisions.20 This appendix summarizes the ACA provisions that were included in the enacted appropriations legislation for FY2011 and FY2012. It also provides for each of those years a brief overview of the ACA-related provisions that were added to both the Labor-HHS-Education and the Financial Services and General Government appropriations acts introduced and, in most cases, reported by the House and Senate Appropriations Committees. Only a few of those provisions were incorporated in the final omnibus appropriations bills for FY2011 and FY2012 that were signed into law. The appendix also provides some discussion of the ACA provisions in FY2013 appropriations legislation. Congress has yet to complete action on any FY2013 appropriations bills. Currently, the federal government is operating under a six-month continuing resolution (P.L. 112-175); see discussion below under “FY2013 Appropriations”. FY2011 Appropriations On April 15, 2011, the Department of Defense and Full-Year Continuing Appropriations Act, 2011 (P.L. 112-10, H.R. 1473), was signed into law, marking the completion of the FY2011 appropriations process more than six months after the beginning of the fiscal year. Prior to the enactment of P.L. 112-10, the President signed seven FY2011 interim continuing resolutions to fund the federal government. P.L. 112-10 included the FY2011 Department of Defense regular appropriations act and extended funding for the remaining 11 regular appropriations acts through the end of FY2011, generally at the annualized rate provided in FY2010, but with spending adjustments for numerous specified programs and activities. Division B, Title VIII of P.L. 112-10 (Labor-HHS-Education) included the following ACA-related provisions: (1) canceled $2.2 billion of the original $6 billion appropriation for the CO-OP program; (2) repealed the free choice voucher program that would have required certain employers to provide vouchers to qualified employees for purchasing coverage through a health insurance exchange; (3) prohibited transfers from the Public Health and Social Services Emergency Fund to pay for the new U.S. Public Health Sciences Track; (4) removed the maintenance of effort requirement for use of the CHCF funds; and (5) mandated a GAO study of the costs and processes of ACA implementation, and a Medicare actuarial analysis of the impact of ACA’s private insurance reforms on employer-sponsored health insurance premiums. [Note: 20 House rules prohibit legislative language that establishes new law, or that amends or repeals current law, in regular appropriations bills and supplemental appropriations measures. However, they do not prohibit such provisions in continuing resolutions. These rules may be waived in a special rule adopted by the Rules Committee prior to floor consideration of the appropriations bill or conference report. A comparable rule in the Senate prohibits legislative language in both Senate Appropriations Committee amendments and non-committee amendments. For more information, see CRS Report R42388, The Congressional Appropriations Process: An Introduction, by Jessica Tollestrup. Congressional Research Service 28 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act The House passed but the Senate rejected an enrollment correction to H.R. 1473 (H.Con.Res. 35) that would have prohibited using any of the funds provided in P.L. 112-10 or in any previous act to implement ACA.] Several months prior to the enactment of P.L. 112-10, on August 2, 2010, the Senate Appropriations Committee reported its version of the FY2011 Labor-HHS-Education appropriations bill (S. 3686). The measure instructed the HHS Secretary to allocate the PPHF funds for FY2011 (i.e., $750 million) to the programs specified, and in the amounts specified, in a table included in the accompanying committee report (S.Rept. 111-243). The House Appropriations Subcommittee on Labor-HHS-Education also approved a draft FY2011 bill, but the full committee took no further action on it. On February 19, 2011, the House by a vote of 235189 passed its version of a full-year continuing resolution for FY2011 (H.R. 1). The bill included nine separate but overlapping provisions that would have prohibited using any of the discretionary funds provided in the bill to implement specific ACA provisions or the entire law. The Senate subsequently rejected H.R. 1 by a vote of 44-56 on March 9, 2011. FY2012 Appropriations The Consolidated Appropriations Act, 2012 (P.L. 112-74, H.R. 2055), which included nine FY2012 appropriations acts, was signed into law on December 23, 2011. Division F of P.L. 11274 (Labor-HHS-Education) included the following ACA-related provisions: (1) rescinded $400 million of the remaining $3.8 billion for the CO-OP program; see P.L. 112-10, above; (2) rescinded $10 million of IPAB’s $15 million appropriation for FY2012; (3) instructed the HHS Secretary to establish a website with detailed information on the allocation and use of FY2012 PPHF funds; and (4) prohibited the use of PPHF funds for lobbying, publicity, or propaganda purposes. Prior to the enactment of P.L. 112-74, the House and Senate Appropriations Committees took the following actions on the FY2012 Labor-HHS-Education and the FY2012 Financial Services and General Government appropriations acts: • The chairman of the House Appropriations Subcommittee on Labor-HHSEducation introduced a chairman’s bill (H.R. 3070) on September 29, 2011, but the subcommittee did not mark up or report the measure to the full committee. The bill received no full committee action. H.R. 3070, as introduced, included the following ACA-related provisions: (1) rescinded the entire FY2012 appropriations for CHCF, PPHF, IPAB, the pregnancy assistance grants, the home visitation program, state ADRCs, and the health workforce demonstration grants; (2) rescinded all the remaining CO-OP funds (i.e., $3.8 billion); (3) rescinded $1.862 billion of the $10 billion appropriation for CMMI for the period FY2011-FY2019; and (4) prohibited using any of the discretionary funds provided in the bill to implement and administer ACA until 90 days after all ACA legal challenges are complete. • The House Appropriations Committee reported the Financial Services and General Government Appropriations Act, 2012 (H.R. 2434, H.Rept. 112-136) on July 7, 2011. The measure included the following two ACA-related provisions: (1) prohibited the IRS from using any of the discretionary funds provided in the bill to implement the ACA individual mandate; and (2) prohibited the transfer of any ACA funds to the IRS. Congressional Research Service 29 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act • The Senate Appropriations Committee reported the Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2012 (S. 1599) on September 22, 2011. Similar to the previous year’s bill, S. 1599, as reported, instructed the HHS Secretary to allocate the PPHF funds for FY2012 (i.e., $1 billion) to the programs specified, and in the amounts specified, in a table included in the accompanying committee report (S.Rept. 112-84). In addition, S.Rept. 112-84 included language directing the HHS Secretary to submit a detailed report on all the recipients of PPHF funding. • The Senate Appropriations Committee reported the Financial Services and General Government Appropriations Act, 2012 (S. 1573) on September 15, 2011. The measure did not include any ACA provisions. However, the accompanying committee report (S.Rept. 112-79) directed the IRS to submit a detailed table itemizing each fund transfer from HHS to the IRS for the purpose of ACA implementation. FY2013 Appropriations The President’s FY2013 budget requested more than $1 billion in new discretionary funding for CMS and the IRS to pay for ongoing ACA administrative costs. It remains unclear, however, whether congressional appropriators will provide those funds. Prior to FY2013, federal administrative costs associated with ACA implementation were supported with mandatory funds from the $1 billion Health Insurance Reform Implementation Fund (HIRIF); see the HIRIF entries in Table 1 and Table 2. The HIRIF funds were projected to have all been obligated by the end of FY2012. Congress has yet to complete action on any of the FY2013 appropriations bills. Instead, it has passed, and the President has signed, a continuing resolution to provide temporary funding for the first six months of FY2013. The Continuing Appropriations Resolution, 2013 (P.L. 112-175, H.J.Res. 117) funds government operations for most discretionary programs at an estimated annualized rate of $1.047 trillion, which equals the FY2013 discretionary spending cap set by the BCA. It increases funding for most federal agencies and programs by 0.612% over the FY2012 levels.21 P.L. 112-175 does not incorporate any of the new ACA funding that was requested in the President’s FY2013 budget. In the 112th Congress, the House and Senate Appropriations Committees took the following actions on the FY2013 Labor-HHS-Education and the FY2013 Financial Services and General Government appropriations acts: • The House Appropriations Subcommittee on Labor-HHS-Education approved a draft bill for FY2013 on July 18, 2012, but no further action was taken. The measure did not include any of the new CMS funds requested in the President’s FY2013 budget for ACA implementation, and it prohibited using any of the discretionary funding provided in the bill to support CMS’s Center for Consumer Information and Insurance Oversight (CCIIO). The draft bill also included the following ACA-related provisions: (1) rescinded the entire FY2013 21 For more information, see CRS Report R42782, FY2013 Continuing Resolution: Analysis of Components and Congressional Action, by Jessica Tollestrup. Congressional Research Service 30 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act appropriations for PPHF and IPAB, and rescinded the base appropriation of $150 million for PCORTF; (2) rescinded $3 billion of the remaining $3.4 billion for the CO-OP funds (see P.L. 112-74, above); (3) rescinded $1.590 billion of the $10 billion appropriation for CMMI for the period FY2011-FY2019; (4) rescinded $300 million of the $1.5 billion CHCF appropriation in FY2013 for community health centers; (5) prohibited using any of the discretionary funds provided in the bill to implement and administer ACA; (6) instructed the HHS Secretary to establish a website with detailed information on the allocation and use of FY2013 PPHF funds; and (7) prohibited the use of PPHF funds for lobbying, publicity, or propaganda purposes. • The House Appropriations Committee reported the Financial Services and General Government Appropriations Act, 2013 (H.R. 6020, H.Rept. 112-550) on June 26, 2012. The measure did not include any of the new IRS funds requested in the President’s FY2013 budget for ACA implementation. H.R. 6020 prohibited the IRS from using any of the discretionary funds provided in the bill to carry out the transfer of ACA funds to the agency. • The Senate Appropriations Committee reported the Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2013 (S. 3295) on June 14, 2012. Again, similar to the bills for the previous two fiscal years, S. 3295, as reported, instructed the HHS Secretary to allocate the PPHF funds for FY2013 (i.e., $1 billion, reflecting the rescission in P.L. 112-96) to the programs specified, and in the amounts specified, in a table included in the accompanying committee report (S.Rept. 112-176). In addition, the bill directed the HHS Secretary to establish a website with detailed information on the allocation and use of PPHF funds. • The Senate Appropriations Committee reported the Financial Services and General Government Appropriations Act, 2013 (S. 3301) on June 14, 2012. The measure did not include any ACA provisions. However, the accompanying committee report (S.Rept. 112-177) directed the IRS to submit a detailed table itemizing each HIRIF fund transfer to the IRS for the purpose of ACA implementation. Author Contact Information C. Stephen Redhead Specialist in Health Policy credhead@crs.loc.gov, 7-2261 Acknowledgments The following analysts have contributed to this report: Kirsten Colello, Patricia Davis, Gary Guenther, Elayne Heisler, Lisa Herz, Janet Kinzer, Sarah Lister, Alison Mitchell, Bernice Reyes, Amanda Sarata, Pamela Smith, Carmen Solomon-Fears, Emilie Stoltzfus, and Susan Thaul. Congressional Research Service 31