Discretionary Spending Under the Affordable Care Act (ACA)

Discretionary FundingSpending in the Patient Protection and Affordable Care Act (ACA) C. Stephen Redhead, Coordinator Specialist in Health Policy Kirsten J. Colello Specialist in Health and Aging Policy Elayne J. Heisler Analyst in Health Services Sarah A. Lister Specialist in Public Health and Epidemiology Amanda K. Sarata Specialist in Health Policy December 16, 2011October 1, 2012 Congressional Research Service 7-5700 www.crs.gov R41390 CRS Report for Congress Prepared for Members and Committees of Congress Discretionary FundingSpending in the Patient Protection and Affordable Care Act (ACA) Summary The Patient Protection and Affordable Care Act (ACA) reauthorized new funding for numerous existing discretionary grant programs and other programs and activities. ACA also created multiple new discretionary grant programs and activities and provided for each an authorization of appropriations. Funding for all of these programs and activities for all these discretionary programs is subject to action by congressional appropriators. This report summarizes all the discretionary spending provisions in ACA that authorized appropriations for grant programs and other activities ACA. A companion product, CRS CRS Report R41301, Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act (PPACA), summarizes all the mandatory appropriations and Medicare trust fund transfers in the new in the law. Among the provisions that are intended to strengthen the nation’s health care safety net and improve access to care, ACA permanently reauthorized the federal health centers program and the National Health Service Corps (NHSC). The NHSC provides scholarships and student loan repayments to individuals who agree to a period of service as a primary care provider in a federally designated Health Professional Shortage Area. In addition, the new law addressed concerns ACA addressed concerns about the current size, specialty mix, and geographic distribution of the health care workforce. It reauthorized and expanded existing health workforce education and training programs under Titles VII and VIII of the Public Health Service Act (PHSA). Title VII supports the education and training of physicians, dentists, physician assistants, and public health workers through grants, scholarships, and loan repayment. ACA created several new programs to increase training training experiences in primary care, in rural areas, and in community-based settings, and provided provided training opportunities to increase the supply of pediatric subspecialists and geriatricians. It also expanded the nursing workforce development programs authorized under PHSA Title VIII to to bolster undergraduate and graduate nursing education and training. As part of a comprehensive framework for federal community-based (i.e., public health) preventionpublic health activities, including a national strategy and a national education and outreach campaign, ACA authorized several new grant programs with a focus on preventable or modifiable risk factors for disease (e.g., sedentary lifestyle, tobacco use). The new law also leveraged a number of mechanisms to improve the quality of health care, including new requirements for quality measure development, collection, analysis, and public reporting; programs to develop and disseminate innovative strategies for improving the quality of health care delivery; and support for care coordination programs such as medical homes, patient navigators, and the co-location of primary health care and mental health services. Additionally, ACA authorized funding for programs to prevent elder abuse, neglect, and exploitation; grants to expand trauma care services and improve regional coordination of emergency services; and demonstration projects to implement alternatives to current tort litigation for resolving medical malpractice claims, among other provisions. The Congressional Budget Office estimated that ACA’s discretionary spending provisions, if fully funded by future appropriations acts, would result in appropriations of approximately $106100 billion over the 10-year period FY2010-FY2019FY2012-FY2021. Most of that funding would be for grant programs that existed prior to, and whose funding was reauthorized by, ACA. Few new programs created by ACA received funding in FY2010 or FY2011. Congressional Research Service Discretionary FundingFY2011 or FY2012. ACA also appropriated $1 billion to cover the administrative costs associated with implementing the new law. All those funds will have been obligated by the end of FY2012. The President’s FY2013 budget requested more than $1 billion in discretionary funding for ongoing ACA administrative costs, though it is unclear whether congressional appropriators will provide any of these funds. Congressional Research Service Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) Contents Introduction...................................................................................................................................... 1 Discretionary FundingSpending in ACA ........................................................................................................ 2 Potential Impact of Automatic Spending Reductions on Discretionary Spending .................... 4 Appropriations and Trust Fund Transfers in ACA........................................................................... 5 Tables Table 1. ACA Discretionary Funding: Health Centers and Clinics.................................................. 6 Table 2. ACA Discretionary Funding: Health Care Workforce ....................................................... 7 Table 3. ACA Discretionary Funding: Prevention and Wellness ................................................... 17 Table 4. ACA Discretionary Funding: Maternal and Child Health................................................ 21 Table 5. ACA Discretionary Funding: Health Care Quality .......................................................... 21 Table 6. ACA Discretionary Funding: Nursing Homes ................................................................. 25 Table 7. ACA Discretionary Funding: Health Disparities Data Collection ................................... 26 Table 8. ACA Discretionary Funding: Emergency Care................................................................ 27 Table 9. ACA Discretionary Funding: Elder Justice...................................................................... 28 Table 10. ACA Discretionary Funding: Biomedical Research ...................................................... 30 Table 11. ACA Discretionary Funding: Biologics ......................................................................... 30 Table 12. ACA Discretionary Funding: 340B Drug Pricing .......................................................... 31 Table 13. ACA Discretionary Funding: Medical Malpractice ....................................................... 31 Table 14. ACA Discretionary Funding: Pain Care Management ................................................... 32 Table 15. ACA Discretionary Funding: Medicaid Demonstrations ............................................... 32 Table 16. ACA Discretionary Funding: Medicare ......................................................................... 33 Table 17. ACA Discretionary Funding: Private Health Insurance ................................................. 33 Contacts Author Contact Information........................................................................................................... 34 Acknowledgments ......................................................................................................................... 34 Key Policy Staff............................................................................................................................. 34 Congressional Research Service Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) Introduction The Patient Protection and Affordable Care Act (ACA)1 restructured the private health insurance market, set minimum standards for health coverage, created a mandate for most U.S. residents to obtain health insurance coverage, and provided for the establishment by 2014 of state-based 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. The new law also expanded eligibility for Medicaid; amended the Medicare program in an effort to reduce the rate of its projected growth; imposed an excise tax on insurance plans found to have high premiums; and made numerous other changes to the tax code, Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and many other federal programs. ACA implementation is projected to have a significant impact on federal revenues and direct (also referred to as mandatory) spending.2 The law included direct spending to subsidize the purchase of health insurance coverage through the exchanges, as well as increased outlays for the expansion of the Medicaid program. ACA also included numerous mandatory appropriations to fund temporary programs to increase access and funding for targeted groups, provide funding to states to plan and establish exchanges, and support many other research and demonstration programs and activities. The costs of expanding public and private health insurance coverage and other mandatory spending are offset by revenues from new taxes and fees, and by savings from payment and health care delivery system reforms designed to slow the growth in spending on Medicare and other federal health care programs. Implementation of ACA is also likely to affect discretionary spending that is subject to the annual appropriations process.3 The law reauthorized appropriations for numerous existing discretionary grant programs and activities, primarily ones authorized under the Public Health Service Act (PHSA). While the authorizations of appropriations for most of these programs expired prior to their reauthorization by ACA, almost all of them continued to receive an annual appropriation. ACA also created multiple new grant programs and provided for each an authorization of appropriations. Funding for all ACA’s discretionary programs depends on actions taken by congressional appropriators, a process that may lead to greater or smaller amounts than the sums authorized by the law. With Congress now operating under discretionary spending limits set by the Budget Control Act, it may prove difficult to secure funding for new programs and activities.4 Even 3 ACA Administrative Costs and Funding ................................................................................... 4 Mandatory Appropriations in ACA.................................................................................................. 5 Impact of Spending Cuts Under the Budget Control Act................................................................. 6 BCA Background....................................................................................................................... 6 FY2013 Nondefense Discretionary Spending Reductions ........................................................ 7 Tables Table 1. ACA Discretionary Spending: Health Centers and Clinics................................................ 9 Table 2. ACA Discretionary Spending: Health Care Workforce.................................................... 10 Table 3. ACA Discretionary Spending: Prevention and Wellness ................................................. 21 Table 4. ACA Discretionary Spending: Maternal and Child Health .............................................. 24 Table 5. ACA Discretionary Spending: Health Care Quality......................................................... 25 Table 6. ACA Discretionary Spending: Nursing Homes................................................................ 29 Table 7. ACA Discretionary Spending: Health Disparities Data Collection.................................. 30 Table 8. ACA Discretionary Spending: Emergency Care and Trauma Services............................ 31 Table 9. ACA Discretionary Spending: Elder Justice .................................................................... 32 Table 10. ACA Discretionary Spending: Biomedical Research..................................................... 34 Table 11. ACA Discretionary Spending: Biologics........................................................................ 34 Table 12. ACA Discretionary Spending: 340B Drug Pricing ........................................................ 35 Table 13. ACA Discretionary Spending: Medical Malpractice...................................................... 35 Table 14. ACA Discretionary Spending: Pain Care Management ................................................. 36 Table 15. ACA Discretionary Spending: Medicaid........................................................................ 36 Table 16. ACA Discretionary Spending: Medicare........................................................................ 37 Table 17. ACA Discretionary Spending: Private Health Insurance ............................................... 37 Contacts Author Contact Information........................................................................................................... 38 Acknowledgments ......................................................................................................................... 38 Key Policy Staff............................................................................................................................. 38 Congressional Research Service Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) Introduction The Patient Protection and Affordable Care Act (ACA)1 makes 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), or 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. In National Federation of Independent Business v. Sebelius, the U.S. Supreme Court found that the Medicaid expansion violated the Constitution by threatening states with the loss of their existing federal Medicaid matching funds. 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 Children’s Health Insurance Program (CHIP), and other federal programs. Implementation of ACA is projected to have a significant impact on federal revenues and direct (also referred to as mandatory) spending.2 The law includes direct spending to subsidize the purchase of health insurance coverage through the exchanges, as well as increased outlays for the expansion of the Medicaid program. ACA also includes numerous mandatory appropriations to fund temporary programs to increase access and funding for targeted groups, provide funding to states to plan and establish exchanges, and support many other research and demonstration programs and activities (see discussion below under “Mandatory Appropriations in ACA”). The costs of expanding public and private health insurance coverage and other mandatory spending are offset by revenues from new taxes and industry fees, and by savings from payment and health care delivery system reforms designed to slow the growth in spending on Medicare and other federal health care programs.3 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 Congressand 112th Congresses made more targeted changes to specific ACA provisions. 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 Mandatory, or directDirect, or mandatory, spending generally refers to budget authority (i.e., the authority to incur financial obligations that result in government expenditures, such as purchasing services or awarding grants) that is provided in laws other than the annual appropriations acts. Mandatory spending includes entitlement authority (e.g., Medicare, Social Security). 3 Discretionary spending refers to outlays from budget authority that is provided in and controlled by annual appropriations acts. 4 For a detailed examination of all the provisions in the Budget Control Act, see CRS Report R41965, The Budget (continued...) Congressional Research Service 1 Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) maintaining current funding levels for existing programs with an established appropriations history may prove a challenge under growing pressure to reduce federal discretionary spending. This report summarizes all the discretionary spending provisions in ACA that authorize (or reauthorize) appropriations for grant programs and other activities. It will be updated to reflect important legislative and other developments. Discretionary Funding in ACA The law’s discretionary funding provisions are grouped by general topic in a series of tables with the following headings: Health Centers and Clinics (Table 1); Health Care Workforce (Table 2); For more information on ACA’s provisions and its projected impact on federal revenues and direct spending, see CRS Report R41664, ACA: A Brief Overview of the Law, Implementation, and Legal Challenges, coordinated by C. Stephen Redhead. Congressional Research Service 1 Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) 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 be 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, all other provisions of ACA remain fully intact and operative. ACA implementation affects not only direct spending and revenues but also discretionary spending, which is subject to the annual appropriations process.4 The law includes numerous discretionary spending provisions that authorize the appropriation of funds to implement grant programs and other activities. These provisions are of two kinds: • Authorizations of appropriations for new discretionary grant and other programs created by ACA. • Authorizations of appropriations for existing programs, primarily ones authorized under the Public Health Service Act (PHSA). In most instances, the appropriation authorizations for these established programs expired prior to their reauthorization by ACA. However, almost all of them continued to receive an annual appropriation.5 Many of the ACA discretionary spending provisions authorize annual appropriations of specified amounts for one or more fiscal years to carry out the program or activity. Other provisions authorize the appropriation of specified amounts for FY2010 or FY2011 and unspecified amounts—such sums as may be necessary, or SSAN—for later years. A few provisions authorize multi-year appropriations, available for obligation for a period in excess of one fiscal year (e.g., for the period FY2011 through FY2014). Numerous other provisions simply authorize the appropriation of SSAN, in a few cases without specifying any fiscal years. Funding for all discretionary programs in ACA depends on actions taken by congressional appropriators, a process that may lead to greater or smaller amounts than the sums authorized by the law. With Congress now operating under discretionary spending limits set by the Budget Control Act, it may prove difficult to secure funding for new programs and activities (see discussion below under “Impact of Spending Cuts Under the Budget Control Act”). Even 4 Discretionary spending refers to outlays from budget authority that is provided in and controlled by annual appropriations acts. 5 ACA also reauthorized the Indian Health Care Improvement Act (IHCIA), which includes many discretionary Indian Health Service (IHS) programs and services. It extended indefinitely the authorizations of appropriations for those programs and services. For more information on ACA’s Indian health provisions, which are not included in this report, see CRS Report R41630, The Indian Health Care Improvement Act Reauthorization and Extension as Enacted by the ACA: Detailed Summary and Timeline, by Elayne J. Heisler. Congressional Research Service 2 Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) maintaining current funding levels for existing programs with an established appropriations history may prove a challenge under growing pressure to reduce federal discretionary spending. This report, which is periodically revised and updated to reflect important legislative and other developments, summarizes all the discretionary spending provisions in ACA that authorize (or reauthorize) appropriations for grant programs and other activities. It also includes a brief discussion of funding for ACA’s administrative costs and some analysis of the potential impact of sequestration triggered by the Budget Control Act on ACA discretionary spending in FY2013. Discretionary Spending in ACA The law’s discretionary spending provisions are organized by general topic in a series of tables with the following headings: Health Centers and Clinics (Table 1); Health Care Workforce (Table 2); Prevention and Wellness (Table 3); Maternal and Child Health (Table 4); Health Care Quality (Table 5); Nursing Homes (Table 6); Health Data Collection (Table 7); Emergency Care (Table 8); Elder Justice (Table 9); Biomedical Research (Table 10); Biologics (Table 11); 340B Drug Pricing (Table 12); Medical Malpractice (Table 13); Pain Care Management (Table 14); Medicaid Demonstrations (Table 15); Medicare (Table 16); and Private Health Insurance (Table 17). Each table row includes the following information: (1) the ACA section number; (2) an indication of whether the provision modifies the PHSA or another law either by amending an existing section or subsection or by adding a new one, or whether it creates new stand-alone statutory authority, as well as the name (if known) of the administering agency or office within the Department of Health and Human Services (HHS); (3) a brief description of the program or activity, including the FY2010 and FY2011 funding amounts for new and existing programs and activities that received an appropriation;5 (4) where applicable, the types of entities and/or individuals eligible for funding;6 and (5) details of the authorization of appropriations. Where available, the table entry includes the Catalog of Federal Domestic Assistance (CFDA) number for the grant program.7 Unless otherwise stated, all references in the tables to the Secretary refer to the HHS Secretary. Many of the discretionary spending provisions summarized in the tables authorize annual appropriations of specified amounts for one or more fiscal years to carry out the program or activity. Other provisions authorize the appropriation of specified amounts for FY2010 or FY2011 and unspecified amounts—such sums as may be necessary, or SSAN—for later years. A (...continued) Control Act of 2011, by Bill Heniff Jr., Elizabeth Rybicki, and Shannon M. Mahan. 5 The FY2010 and FY2011 funding amounts that appear in the tables in this report are taken from the HHS agency FY2011 operating plans, available at http://www.hhs.gov/asfr/ob/docbudget/2011operatingplan.html, and the agency congressional budget justification documents, available at http://www.hhs.gov/about/hhsbudget.html. FY2012 funding amounts will be incorporated in the tables once the HHS FY2012 annual appropriations are enacted and figures become available. For more information on funding for the Public Health Service agencies within HHS, see CRS Report R41737, Public Health Service (PHS) Agencies: Overview and Funding, FY2010-FY2012, coordinated by C. Stephen Redhead and Pamela W. Smith. 6 Not applicable if the funding is to support programs and activities carried out by a federal agency. 7 17). 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 name of the administering agency or office within HHS is also included, if known. The third column provides a brief description of the program or activity, including the types of entities and/or individuals eligible for funding.6 The fourth column gives details of the authorization of appropriations, along with the FY2011 and FY2012 amounts for programs and activities that received funding, and, if applicable, the FY2013 funding request.7 The federal government currently is operating under a six-month continuing resolution (see discussion below under ““ACA Administrative Costs and Funding”). Note that in several of the larger tables with multiple entries (i.e., Tables 1, 2, 3, 5 and 8), the ACA provisions are grouped based on whether they reauthorize funding for existing programs or authorize funding for new programs. Where available, the table entry includes the Catalog of Federal Domestic Assistance (CFDA) number for the grant program.8 Unless otherwise stated, all references in the tables to the Secretary refer to the HHS Secretary. The Congressional Budget Office (CBO) estimated that ACA’s discretionary spending provisions, if fully funded by future appropriations acts, would result in appropriations of almost $100 billion over the period FY2012-FY2021.9 However, much of that funding—about $85 billion—would be 6 Not applicable if the funding is to support programs and activities carried out by a federal agency. The FY2011, FY2012, and FY2013 (request) funding amounts are taken from HHS agency FY2013 congressional justification documents, available at http://www.hrsa.gov/about/budget/index.html. 8 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. 9 U.S. Congress, House Committee on Energy and Commerce, Subcommittee on Health, “CBO’s Analysis of the Major (continued...) 7 Congressional Research Service 23 Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) few provisions authorize multi-year appropriations, available for obligation for a period in excess of one fiscal year (e.g., for the period FY2011 through FY2014). Numerous other provisions simply authorize the appropriation of SSAN, in a few cases without specifying any fiscal years. ACA also reauthorized the Indian Health Care Improvement Act (IHCIA), which authorizes many programs and services provided by the Indian Health Service (IHS). It also extended indefinitely the authorization of appropriations for IHCIA programs. For more information on ACA’ s Indian health provisions, which are not included in this report, see CRS Report R41630, The Indian Health Care Improvement Act Reauthorization and Extension as Enacted by the ACA: Detailed Summary and Timeline, by Elayne J. Heisler.Spending in the Patient Protection and Affordable Care Act (ACA) for three programs that were in existence prior to, and were reauthorized by, ACA; namely, the National Health Service Corps, the federal health centers program, and the Indian Health Service (IHS). Most, though not all, of the existing grant programs that were reauthorized under ACA received a discretionary appropriation for FY2011 and FY2012, as well as a FY2013 request for continued funding. In contrast, few of the new grant programs authorized under ACA have received annual discretionary appropriations.10 However, several of the new programs have received mandatory funds from ACA’s Prevention and Public Health Fund (see discussion below under “Mandatory Appropriations in ACA”). ACA Administrative Costs and Funding Acronyms Used in the Tables in This Report Agency for Healthcare Research and Quality (AHRQ) Centers for Disease Control and Prevention (CDC) Centers for Medicare and Medicaid Services (CMS) Community Health Center Fund (CHCF) Federal Food, Drug, and Cosmetic Act (FFDCA) Food and Drug Administration (FDA) Health Resources and Services Administration (HRSA) Indian Health Service (IHS) National Institutes of Health (NIH) Office of Personnel Management (OPM) The Congressional Budget Office (CBO) estimated that ACA’s discretionary spending Office of the Secretary (OS) provisions, if fully funded by future Prevention and Public Health Fund (PPHF) appropriations acts, would result in Public Health Service Act (PHSA) appropriations of approximately $106 billion 8 over the period FY2010-FY2019. However, Substance Abuse and Mental Health Services Administration (SAMHSA) much of that funding—about $82 billion—is for three programs that were in existence prior Social Security Act (SSA) to, and whose funding was reauthorized by, ACA; namely, the National Health Service Corps, the federal health centers program, and the IHS. In addition, CBO projected that both the Department of Health and Human Services (HHS) and the Internal Revenue Service (IRS) will incur substantial costs to implement the policies and programs established by ACA. Most of these costs will have to be funded through the annual appropriations process Office of Personnel Management (OPM) Office of the Secretary (OS) Prevention and Public Health Fund (PPHF) In addition to the costs of fully funding ACA’s discretionary grant programs and other Public Health Service Act (PHSA) activities, CBO projected that both HHS and Substance Abuse and Mental Health Services the Internal Revenue Service (IRS) will incur Administration (SAMHSA) substantial administrative costs to implement Social Security Act (SSA) the law’s private health insurance reforms and its changes to the federal health care programs. CBO estimated that the costs to the IRS of implementing the eligibility determination, documentation, and verification processes for the health insurance subsidies will probably total between $5 billion and $10 billion over 10 years. It further estimated that the costs to HHS of implementing the changes in Medicare, Medicaid, and CHIP, as well as some of the reforms to the private insurance market, will require similar amounts over 10 years.9 8 U.S. Congressional Budget Office, letter to the Honorable Jerry Lewis about the potential effects of the Patient Protection and Affordable Care Act on discretionary spending, May 11, 2010, available at http://www.cbo.gov/ftpdocs/ 114xx/doc11490/LewisLtr_HR3590.pdf. CBO’s estimate of discretionary spending includes (1) amounts specified in ACA, plus estimated amounts for subsequent years (adjusted for anticipated inflation) where ACA specifies an amount for the first year (FY2010 or FY2011) and authorizes SSAN for subsequent years; and (2) estimated amounts for subsequent years (adjusted for anticipated inflation) where there is an appropriation under prior law for FY2010 and ACA authorizes the appropriation of SSAN for later years. The CBO estimate does not include new ACA programs for which the law provided only an authorization for the appropriation of SSAN. 9 Ibid. Section 1105 of the Health Care and Education Reconciliation Act established a Health Insurance Reform Implementation Fund (HIRIF) within HHS and appropriated $1 billion to the Fund to implement ACA. CBO’s estimates of the amount of discretionary funding necessary to implement ACA are in addition to the funding provided (continued...) Congressional Research Service 3 Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) For FY2010 and FY2011, it appears that none of the new discretionary programs authorized under ACA received funding through the regular appropriations process. However, three new programs received mandatory funds from ACA’s Prevention and Public Health Fund (see discussion below under “Appropriations and Trust Fund Transfers in ACA”).10 Potential Impact of Automatic Spending Reductions on Discretionary Spending The Budget Control Act of 2011 (BCA)11 established new budgetary enforcement mechanisms for reducing the federal deficit by at least $2.1 trillion over the 10-year period FY2012-FY2021. The BCA placed statutory limits, or caps, on discretionary spending for each of those 10 fiscal years, which will save an estimated $0.9 trillion during that period. In addition, it created a Joint Select Committee on Deficit Reduction (Joint Committee) with instructions to develop legislation to reduce the budget deficit by at least another $1.5 trillion through FY2021. The Joint Committee had until November 23, 2011, to approve a legislative proposal and have it considered by the House and Senate under special procedures that would prevent amendments and limit debate in both chambers. If a Joint Committee bill reducing the deficit by at least $1.2 billion over the period FY2012-FY2021 is not signed into law by January 15, 2012, then automatic spending reductions will be triggered beginning in FY2013. On November 21, 2010, the Joint Committee announced that the group had been unable to reach agreement on a legislative proposal to cut the deficit, raising the likelihood that automatic spending reductions will occur.12 Under the BCA, the spending reductions would take the form of equal cuts (in dollar terms) in defense and nondefense spending for each fiscal year over the period FY2013-FY2021. The annual amount of spending cuts required in each of these two categories would be divided proportionately between direct and discretionary spending. Cuts in nonexempt direct spending programs—both defense and nondefense—would be executed through sequestration (i.e., an across-the-board cancellation of budgetary resources). Discretionary spending reductions in FY2013 also would be achieved through a sequestration of nonexempt discretionary appropriations, with any reduction in funding for health centers and the IHS capped at 2%. For each of the remaining fiscal years (i.e., FY2014-FY2021) discretionary spending reductions would be achieved through a downward adjustment of the statutory limits for defense and nondefense spending. In contrast to the automatic spending reductions achieved through sequestration, lowering the annual discretionary spending limits allows Congress and the President to determine through the annual appropriations process which accounts are to be reduced, and by how much, in order to meet those limits. Lowering the annual spending limits also would make it that much more of a challenge to maintain funding levels for existing programs, let alone secure funding for new ones. For more information, see CRS Report R42051, (...continued) to the HIRIF. 10 The three programs are (1) Sec. 5208, Nurse-Managed Health Clinics, see Table 1; (2) Sec. 5102, State Health Care Workforce Development Grants, see Table 2; and (3) Sec. 4201, Community Transformation Grants, see Table 3. 11 P.L. 112-25, 125 Stat. 240. 12 The Joint Committee’s statement is at http://www.deficitreduction.gov/public/index.cfm/2011/11/statement-from-cochairs-of-the-joint-select-committee-on-deficit-reduction. Congressional Research Service 4 Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) Budget Control Act: Potential Impact of Automatic Spending Reduction Procedures on Health Reform Spending, by C. Stephen Redhead. Appropriations and Trust Fund Transfers in ACA Separate from the discretionary funding authorities discussed in this report, ACA included numerous provisions that appropriate billions of dollars to fund 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 to support various specified activities. All these mandatory spending provisions are summarized in a companion product, CRS Report R41301, Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act (PPACA), by C. Stephen Redhead. Of particular note, ACA established and appropriated billions of dollars for two new funds to help support HHS programs and activities. First, the Community Health Center Fund (CHCF) will provide a total of $11 billion in supplemental funding over the period FY2011-FY2015 for the federal health centers program and the National Health Service Corps (see Table 1 and Table 2).13 A separate ACA appropriation provided $1.5 billion for health center construction and renovation (see Table 1). Second, the Prevention and Public Health Fund (PPHF), for which ACA provided an annual appropriation in perpetuity,14 is intended to fund prevention, wellness, and other public health-related programs and activities authorized under the PHSA. In addition to funding three of ACA’s new discretionary programs, PPHF funds for FY2010 and/or FY2011 were used to supplement regular appropriations for a number of other longstanding programs that were reauthorized by the law (see Table 2 and Table 3).15 13 The CHCF will provide the following amounts to supplement regular appropriations for health center operating grants: FY2011 = $1 billion; FY2012 = $1.2 billion; FY2013 = $1.5 billion; FY2014 = $2.2 billion; and FY2015 = $3.6 billion. It also will provide the following amounts to supplement regular appropriations for the National Health Service Corps: FY2011 = $290 million; FY2012 = $295 million; FY2013 = $300 million; FY2014 = $305 million; and FY2015 = $310 million. 14 ACA appropriated the following amounts to the PPHF: FY2010 = $500 million; FY2011 = $750 million; FY2012 = $1 billion; FY2013 = $1.25 billion; FY2014 = $1.5 billion; and FY2015 and each fiscal year thereafter = $2 billion. 15 For more information on the allocation of PPHF funds in FY2010 and FY2011, see CRS Report R41737, Public Health Service (PHS) Agencies: Overview and Funding, FY2010-FY2012, coordinated by C. Stephen Redhead and Pamela W. Smith. Congressional Research Service 5 Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) Table 1. ACA Discretionary Funding: Health Centers and Clinics New/Existing Authority (Agency) ACA Section 5601 Permanently reauthorizes PHSA Sec. 330 (HRSA) Summary of Provision and Funding (FY2010-FY2011) Health centers program. Provides operating grants to health centers serving federally designated medically underserved populations and furnishing comprehensive primary care services, referrals, and other services needed to facilitate access to such care, regardless of ability to pay. Eligibility Community, migrant, public housing, and homeless health centers that meet the statutory requirements of PHSA Sec. 330. $3.0 billion for FY2010, $3.9 billion for FY2011, $5.0 billion for FY2012, $6.5 billion for FY2013, $7.3 billion for FY2014, and $8.3 billion for FY2015; amounts in subsequent years based on previous year’s funding, subject to adjustment. SBHCs that meet certain specified criteria and match 20% of the grant amount with nonfederal funds (unless waived). Preference may be given to SBHCs serving children and adolescents who have limited access to or difficulty accessing health care. SSAN for each of FY2010 through FY2014. NMHCs that provide care regardless of income or insurance status and in which nurses provide the majority of the services. At least one advanced practice nurse must hold an executive management position in the NMHC. $50 million for FY2010, and SSAN for each of FY2011 through FY2014. State-based, nonprofit, public-private partnerships that provide access to comprehensive health care services to the uninsured at reduced fees. SSAN (no years specified). FY2010 funding = $2.19 billion; FY2011 funding = $2.58 billion. [Note: FY2011 funding = $1.58 billion in regular appropriations + $1 billion from the CHCF. In addition, ACA appropriated $1.5 billion for the period FY2011 through FY2015 for health center construction and renovation; see CRS Report R41301.] 4101(b) New PHSA Sec. 399Z-1 (HRSA) School-based health centers (SBHCs). Requires the Secretary to award grants to fund the management and operation of SBHCs that provide comprehensive physical and behavioral health services to children and adolescents, subject to parental consent. [Note: ACA Sec. 4101(a) appropriated a total of $200 million for SBHC construction and renovation; see CRS Report R41301.] 5208 New PHSA Sec. 330A-1 (HRSA) Nurse-managed health clinics (NMHCs). Requires the Secretary to award grants to fund the operation of NMHCs— associated with schools, colleges, federally qualified health centers (FQHCs), or nonprofit health/social services agencies—that provide comprehensive primary health care and wellness services to vulnerable or underserved populations. Authorization of Appropriations FY2010 funding = $15 million from the PPHF; FY2011 funding = $0. [CFDA 93.515] 10504 New authority (HRSA) Access to affordable care demonstration program. Within six months of enactment, requires the Secretary to establish a three-year demonstration project in up to 10 states—each state may receive up to $2 million—to provide access to comprehensive health care services to the uninsured. Sources: Table 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 by the health provisions in the Health Care and Education Reconciliation Act of 2010 (HCERA; P.L. 111-152). FY2010 and FY2011 funding amounts are taken from HRSA’s FY2011 operating plan, available at http://www.hhs.gov/asfr/ob/docbudget/2011operatingplan.html, and the agency’s FY2012 congressional budget justification document, available at http://www.hhs.gov/about/hhsbudget.html. CRS-6 Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) Table 2. ACA Discretionary Funding: Health Care Workforce ACA Section New/Existing Authority (Agency) Summary of Provision and Funding (FY2010-FY2011) Eligibility Authorization of Appropriations National Health Service Corps (NHSC) 5207 Permanently reauthorizes PHSA Title III, Part D, Subpart III (HRSA) NHSC scholarships and loan repayments. In exchange for a commitment to work in a federally designated Health Professional Shortage Area (HPSA), provides (1) scholarships to students training in a primary care discipline to cover tuition, fees, other educational costs, and a stipend; and (2) student loan repayments of up to $50,000 a year to primary care and mental health clinicians. FY2010 funding = $141 million; FY2011 funding = $315 million. [Note: FY2011 funding = $25 million in regular appropriations + $290 million from the CHCF; see CRS Report R41301. CFDA 93.162, 93.288] (1) Scholarships: students accepted to or enrolled in a training program for medicine, dentistry, family nurse practitioner, nurse midwife, or physician assistant who agree to two to four years of service in an NHSCapproved site in a HPSA. (2) Loan repayments: primary care, dental, and mental health clinicians who agree to at least two years of service in an NHSC-approved site in a HPSA. $320 million for FY2010, $414 million for FY2011, $535 million for FY2012, $691 million for FY2013, $893 million for FY2014, and $1.155 billion for FY2015; amounts in subsequent years based on previous year’s funding, subject to adjustment. (1) Training grants: public and nonprofit private hospitals, medical schools, academically affiliated physician assistant training programs, and other public and nonprofit private entities. (2) Capacity building grants: medical schools; priority given to entities proposing innovative approaches to primary care training and with a record of training primary care providers, among other things. For both grant programs, $125 million for FY2010, and SSAN for each of FY2011 through FY2014. A separate authorization of $750,000 for each of FY2010 through FY2014 is provided for capacity building grants to integrate academic units. Practicing or in-training pediatric specialists and surgeons, and child and adolescent mental health specialists, who agree to at least 2 years of full-time service in a HPSA. $30 million for each of FY2010 through FY2014 for loan repayments to pediatric specialists and surgeons; $20 million for each of FY2010 through FY2013 for loan repayments to mental health providers. Physicians 5301 Amends and reauthorizes PHSA Sec. 747 (HRSA) Primary care training programs. (1) Authorizes five-year grants to support training programs in primary care. Funds are to be used to plan, develop and operate accredited training programs, including residency and internship programs, in family medicine, general internal medicine, and general pediatrics and to provide financial assistance (e.g., traineeships). (2) Authorizes five-year grants for primary care capacity building. Funds are to be used to create academic units or programs that improve clinical teaching in the primary care fields, and (in a separate authorization) to integrate academic units to enhance interdisciplinary recruitment, training, and faculty development. FY2010 funding = $237 million; FY2011 funding = $39 million. [Note: FY2010 funding = $39 million in regular appropriations + $198 million from the PPHF; see CRS Report R41301. CFDA 93.510, 93.514, 93.884] 5203 CRS-7 New PHSA Sec. 775 (HRSA) Pediatric specialist loan repayment program. Requires the Secretary to implement a loan repayment program that pays up to $35,000 for each year of service (for a maximum of three years) to eligible individuals in exchange for a commitment to work in a pediatric medical specialty, in pediatric surgery, or in child and adolescent mental and behavioral health care in a medically underserved area. Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) ACA Section New/Existing Authority (Agency) Summary of Provision and Funding (FY2010-FY2011) Eligibility Authorization of Appropriations 5508(a) New PHSA Sec. 749A (HRSA) Teaching health centers development grants. Authorizes three-year grants of up to $500,000 to community-based, ambulatory care centers that establish or expand a primary care residency training program. FQHCs, rural health clinics, Indian health centers, and entities receiving PHSA Title X (family planning) funds. $25 million for FY2010, $50 million for each of FY2011 and FY2012, and SSAN for each fiscal year thereafter. 10501(l) New PHSA Sec. 749B (HRSA) Rural physician training grants. Requires the Secretary to (1) award grants for recruiting medical students most likely to practice in underserved rural communities and for providing rural-focused training and experience; and (2) within 60 days of enactment, by regulation, define underserved rural communities. [Note: HRSA published an interim final rule on May 26, 2010 (75 Federal Register 29447).] Medical schools; priority given to entities that train students to practice in rural communities, that have established partnerships with rural community health centers, or who submit a long-term plan for tracking where graduates practice. $4 million for each of FY2010 through FY2013. New PHSA Sec. 748; authority previously part of Sec. 747 (HRSA) General, pediatric, and public health dentistry training. Authorizes grants or contracts for dental training activities including faculty development, financial assistance, faculty loan repayment programs, technical assistance for pediatric dental programs, and pre- and post-doctoral training programs in dental primary care. Gives priority to entities that train individuals from disadvantaged backgrounds, who have a record of placing graduates in facilities that provide care to the underserved, or whose programs focus on providing care to the underserved through demonstrated partnerships with FQHCs, rural health clinics, or through having programs focused on specific topics, such as HIV/AIDs. Dental or dental hygiene schools; approved residency or advanced education programs in general, pediatric, or public health dentistry. Eligible entities may partner with schools of public health so that dental residents and dental hygiene students may receive masterslevel training in public health. $30 million for FY2010, and SSAN for each of FY2011 through FY2015; permits grantees to carry over funds for up to three fiscal years. Institutions of higher education; publicprivate entities; FQHCs; facilities operated by the IHS or by Indian tribes or organizations; state or county public health clinics; public hospitals or health systems; or accredited dental education programs. SSAN (no years specified). Dentistry 5303 FY2010 funding = $15 million; FY2011 funding = $15 million. [CFDA 93.884] 5304 CRS-8 New PHSA Sec. 340G-1 (HRSA) Alternative dental health care provider demonstration program. Authorizes the Secretary to award 15 five-year grants of not less than $4 million to train or employ alternative dental health care providers (e.g., community dental health coordinators, dental health aides) to increase access to dental health care services in rural and other underserved communities. Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) ACA Section New/Existing Authority (Agency) Summary of Provision and Funding (FY2010-FY2011) Eligibility Authorization of Appropriations Nursing 5309(a) Amends and reauthorizes PHSA Sec. 831 (HRSA) Nurse education, practice, and quality grants. Authorizes grants or contracts to expand enrollment in baccalaureate nursing programs; provide training in new technologies; develop cultural competencies; expand nursing practice arrangements in noninstitutional settings; and support nurse retention programs that offer career advancement for nursing personnel, enhance collaboration among nurses and other health professionals, and promote nurse involvement in clinical decision making. Schools of nursing, health care facilities (including NMHCs), or partnerships of the two. SSAN for each of FY2010 through FY2014. See also ACA Sec. 5312 below. FY2010 funding = $40 million; FY2011 funding = $40 million. [CFDA 93.359, 93.503] 5309(b) New PHSA Sec. 831A (HRSA) Nurse retention grants. New authority that largely duplicates the nurse retention grant program authorized under PHSA Sec. 831 (see ACA Sec. 5309(a) above). Schools of nursing, health care facilities (including NMHCs), or partnerships of the two. SSAN for each of FY2010 through FY2012. See also ACA Sec. 5312 below. 5311(a) Amends and reauthorizes PHSA Sec. 846A (HRSA) Nursing faculty loan program. Authorizes loans to nursing school students pursuing advanced degrees to become qualified nursing faculty. Sets the annual loan limit at $35,500 for FY2010 and FY2011; for subsequent fiscal years, the loan limit is subject to a cost-of-attendance adjustment. Students who go on to serve as nursing school faculty may have up to 85% of their loan repayment cancelled. Accredited schools of nursing may operate the student loan programs. SSAN for each of FY2010 through FY2014. U.S. citizens, nationals, or lawful permanent residents who are registered nurses and have either already completed a master’s or doctorate nursing program at an accredited school of nursing or are currently enrolled on a full-time or part-time basis in such a program. SSAN for each of FY2010 through FY2014. FY2010 funding = $25 million; FY2011 funding = $25 million. [CFDA 93.264] 5311(b) CRS-9 New PHSA Sec. 847 (HRSA) Nursing faculty loan repayment program. Authorizes a loan repayment program for qualified nursing students or graduates who agree to serve as nursing faculty for four to six years. Sets the annual loan limit for FY2010 and FY2011 at $10,000 for individuals with a master’s or equivalent degree in nursing ($20,000 for those with a doctorate or equivalent degree in nursing), and an aggregate loan limit of $40,000 for individuals with a master’s or equivalent degree in nursing ($80,000 for those with a doctorate or equivalent degree in nursing). Thereafter, the annual and aggregate loan limits are subject to a cost-of-attendance adjustment. Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) ACA Section 5312 5316 New/Existing Authority (Agency) Amends PHSA Sec. 871; previously Sec. 841 (HRSA) New authority Summary of Provision and Funding (FY2010-FY2011) Authorization of appropriations. Reauthorizes funding for the following PHSA Title VIII programs: • Sec. 811 (grants for the support of advanced education nurses, i.e., nurse practitioners): FY2010 funding = $96 million; FY2011 funding = $64 million. [Note: FY2010 funding = $64 million in regular appropriations + $31 million from the PPHF. CFDA 93.124, 93.247, 93.358, 93.513] • Sec. 821 (grants for nursing workforce diversity): FY2010 funding = $16 million, FY2011 funding = $16 million. [CFDA 93.178] • Sec. 831 (nurse education, practice, and quality grants) and new Sec. 831A (nurse retention grants); see ACA Secs. 5309(a)&(b) above for funding amounts. Family nurse practitioner demonstration program. Requires the Secretary to award three-year demonstration grants, not to exceed $600,000 a year, for programs to train nurse practitioners as primary care providers in FQHCs and NMHCs (as defined in ACA Sec. 5208). Preference given to bilingual individuals. Eligibility Authorization of Appropriations (1) Sec. 811: accredited programs for advanced nurse education including combined registered nurse masters degree programs, authorized nurse practitioner programs, accredited nurse midwifery programs, accredited nurse anesthesia programs, and other programs approved by the Secretary. (2) Sec. 821: schools of nursing, nursing centers, academic health centers, state or local governments, and other appropriate public or private nonprofit entities as determined appropriate by the Secretary. (3) Secs. 831 and 831A: schools of nursing, health care facilities, or partnerships of the two. $338 million for FY2010, and SSAN for each of FY2011 through FY2016. [Note: ACA did not reauthorize funding for the Sec. 846 nursing education loan repayment and scholarship programs.]a FQHCs, NMHCs. SSAN for each of FY2011 through FY2014. Accredited institutions of higher education that have established a partnership with a long-term care setting (e.g., nursing home, home and community based service provider), as specified. $10 million for the period FY2011 through FY2013. Geriatrics and Long-Term Care (LTC) 5302 CRS-10 New PHSA Sec. 747A (HRSA) Direct care worker training. Requires the Secretary to establish a grant program to provide new training opportunities, such as tuition and fee assistance, for direct care workers employed in LTC settings. Individuals who receive assistance are required to work in the field of geriatrics, disability services, LTC services and supports, or chronic care management for a minimum of two years. Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) ACA Section 5305(a) New/Existing Authority (Agency) Amends PHSA Sec. 753 by adding new subsections (d)&(e) (HRSA) Authorization of Appropriations Summary of Provision and Funding (FY2010-FY2011) Eligibility Geriatric workforce development; geriatric career incentive awards. (1) Requires the Secretary to award no more than 24 grants or contracts for $150,000 to eligible entities that operate geriatric education centers to support short-term intensive courses on geriatrics and LTC, and support training for family caregivers and direct care workers. (2) Requires the Secretary to award grants or contracts to eligible individuals pursuing an advanced degree in geriatrics or a related field, in return for agreeing to teach or practice in the field of geriatrics, LTC, or chronic care management for a minimum of five years upon completion of the degree. (1) Accredited schools of allied health, medicine, nursing, dentistry, osteopathic medicine, optometry, podiatric medicine, veterinary medicine, public health, or chiropractic care; accredited graduate programs in clinical psychology, clinical social work, health administration, marriage and family therapy, and counseling; and physician assistant programs. (2) Advanced practice nurse, clinical social worker, pharmacist, or psychology student. (1) $10.8 million for the period FY2011 through FY2014. (2) $10 million for the period FY2011 through FY2013. A school of nursing, a health care facility, a program leading to certification as a certified nurse assistant, or a partnership of a health care facility and one of the other two entities. SSAN for each of FY2010 through FY2014. FY2010 funding = $34 million; FY2011 funding = $34 million. [CFDA 93.156, 93.250, 93.969] 5305(c) Amends and reauthorizes PHSA Sec. 865; previously Sec. 855 (HRSA) Geriatric nursing education and training. Provides traineeships for individuals preparing for advanced degrees in geriatric nursing or other nursing areas that specialize in elder care. New PHSA Sec. 759 (HRSA) Education and training in pain care. Authorizes a grant program to train health professionals in pain care. [See also Table 14.] Health professions schools, hospices, and other public and private entities. Applicants must agree to include training and education on recognizing the signs and symptoms of pain; applicable laws and policies on controlled substances; interdisciplinary approaches to pain care delivery; barriers to care in underserved populations; and recent developments in pain care. SSAN for each of FY2010 through FY2012, to remain available until expended. New PHSA Sec. 776 (HRSA) Public health workforce loan repayment program. Requires the Secretary to establish a student loan repayment program that pays up to $35,000 a year, or one-third of total debt, whichever is less, to increase the supply of public health professionals. Public health or health professionals who agree to work for at least three years in a public health agency or related training fellowship. $195 million for FY2010, and SSAN for each of FY2011 through FY2015. FY2010 funding = $5 million; FY2011 funding = $5 million. [CFDA 93.265] Pain Care 4305(c) Public Health 5204 CRS-11 Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) ACA Section New/Existing Authority (Agency) Summary of Provision and Funding (FY2010-FY2011) Eligibility Authorization of Appropriations 5206(b) New PHSA Sec. 777 (HRSA) Public health and allied health scholarship program. Authorizes grants to eligible educational entities to award scholarships for the training of mid-career professionals in public health and allied health. Available grant funds are to be divided 50:50 between supporting public health and allied health professionals. Accredited institutions that offer training programs in public health and allied health. $60 million for FY2010, and SSAN for each of FY2011 through FY2015. 5313 New PHSA Sec. 399V (CDC) Community health worker (CHW) program. Requires CDC to award grants to promote healthy behaviors and outcomes for populations in medically underserved communities through programs of training and supervision of CHWs. States and subdivisions, health departments, free clinics, hospitals, and FQHCs; priority given to applicants that target areas with a high proportion of uninsured or underinsured individuals, or with high rates of chronic illness or infant mortality. SSAN for each of FY2010 through FY2014. 5314 New PHSA Sec. 778 (CDC) CDC training fellowships. Authorizes the Secretary to expand existing CDC training fellowships in epidemiology, laboratory science, and informatics; the Epidemic Intelligence Service (EIS); and other training programs that meet similar objectives. [CFDA 93.065] Participants may be placed in state and local health agencies, and states can receive federal assistance for loan repayment programs for such participants. $39.5 million for each of FY2010 through FY2013 ($24.5 million for EIS, and $5 million each for epidemiology, laboratory science, and informatics). 5315 New PHSA Title II, Part D – Secs. 271-274 (U.S. Surgeon General) United States Public Health Sciences Track. Authorizes the establishment of a science track at academic sites selected by the Secretary to award degrees that emphasize team-based service, public health, epidemiology, and emergency preparedness and response. Assistance to academic institutions for program development; tuition and stipends for students who meet a service obligation, including in the United States Public Health Service (USPHS) Commissioned Corps. Preference to students from rural communities, and minorities. Requires the Secretary to transfer SSAN from the Public Health and Social Services Emergency Fund for FY2010 and each fiscal year thereafter. [Note: P.L. 112-10 prohibits any such transfer of funds.]b 10501(m)(2) Amends PHSA Sec. 770 (HRSA) Public health workforce programs. Reauthorizes funding for existing public health workforce programs (PHSA Secs. 765-769). They include grants for public health training centers; tuition, fees, and stipends for traineeships in public health and in health administration; and residency programs in preventive medicine and dental public health. Several programs mention preference for underserved communities or underrepresented minorities. Eligible entities for each program are stipulated and generally include accredited academic institutions, but may also include state, local and tribal public health departments and/or other private nonprofit entities. $43 million for FY2011, and SSAN for each of FY2012 through FY2015. FY2010 funding = $25 million; FY2011 funding = $30 million. [Note: Funding for FY2010 and FY2011 included $15 million and $20 million from the PPHF, respectively. CFDA 93.117, 93.236, 93.249, 93.516, 93.964] CRS-12 Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) ACA Section 5210 New/Existing Authority (Agency) Amends PHSA Sec. 203 (U.S. Surgeon General) Summary of Provision and Funding (FY2010-FY2011) USPHS Commissioned Corps. Establishes a Ready Reserve Corps of officers who are subject to involuntary call to active duty (including for training) by the Surgeon General, in order to bolster the available workforce for both routine and emergency public health missions. Eligibility Authorization of Appropriations Not applicable. $17.5 million for each of FY2010 through FY2014 ($5 million for recruitment and training, $12.5 million for the Ready Reserve Corps). Workforce Diversity/Health Disparities 5307(a) Amends and reauthorizes PHSA Sec. 741 (HRSA) Cultural competency, prevention, public health, disparities, and individuals with disability training. Authorizes grants, contracts, or cooperative agreements under PHSA Title VII (Health Professions Education) for the development and evaluation of research, demonstration projects, and model curricula that provide training in cultural competency, prevention, public health proficiency, reducing health disparities, and aptitude for working with individuals with disabilities. Health professions schools, academic health centers, state or local governments, or other appropriate public or private nonprofit entities (or consortia of such entities). SSAN for each of FY2010 through FY2015. 5307(b) Amends and reauthorizes PHSA Sec. 807 (HRSA) Cultural competency, prevention, public health, disparities, and individuals with disability training. Authorizes grants, contracts, or cooperative agreements under PHSA Title VIII (Nursing Workforce Development) for the development and evaluation of research, demonstration projects, and model curricula that provide training in cultural competency, prevention, public health proficiency, reducing health disparities, and aptitude for working with individuals with disabilities. The Secretary is required to coordinate this program with the one authorized under PHSA Sec. 741. Nursing schools, academic health centers, state or local governments, or other appropriate public or private nonprofit entities. SSAN for each of FY2010 through FY2015. 5401 Amends and reauthorizes PHSA Sec. 736 (HRSA) Centers of excellence (COE). Requires the Secretary to fund COE; i.e., centers that sponsor programs related to the recruitment, training and retention of underrepresented minorities in the health professions. Health professions schools that recruit, enroll, and graduate underrepresented minorities or who have increased the recruitment of underrepresented minorities serving in faculty or administrative positions. $50 million for each of FY2010 through FY2015, and SSAN for each subsequent fiscal year. FY2010 funding = $25 million; FY2011 funding = $24 million. [CFDA 93.157] CRS-13 Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) ACA Section 5402 5403(a) New/Existing Authority (Agency) Amends PHSA Sec. 740 (HRSA) Amends and reauthorizes PHSA Sec. 751 (HRSA) Summary of Provision and Funding (FY2010-FY2011) Authorization of appropriations for diversity programs. Reauthorizes appropriations for the following PHSA Title VII programs: • Sec. 737 (scholarships for disadvantaged students): FY2010 funding = $49 million; FY2011 funding = $49 million. [CFDA 93.925] • Sec. 738 (faculty loan repayments and fellowships): FY2010 funding = $1 million; FY2011 funding = $1 million. [CFDA 93.923] • Sec. 739 (educational assistance for individuals from disadvantaged backgrounds): FY2010 funding = $22 million; FY2011 funding = $22 million. [CFDA 93.822] Area Health Education Centers (AHECs). Requires the Secretary to award grants (with a matching requirement) of at least $250,000 to (1) plan, develop, and operate AHEC programs; and (2) to maintain and improve the effectiveness of existing AHEC programs. AHECs recruit, train, and prepare individuals from minority populations or from disadvantaged or rural backgrounds to work in medically underserved areas. Eligibility Authorization of Appropriations Sec. 737: health professions schools. Sec. 738: individuals from disadvantaged backgrounds who are in their final year of study or have a degree from an accredited health professions school. Sec. 739: health professions schools. For Sec. 737, $51 million for FY2010, and SSAN for each of FY2011 through FY2014. For Sec. 738, $5 million for each of FY2010 through FY2014. For Sec. 739, $60 million for FY2010, and SSAN for each of FY2011 through FY2014. Medical and nursing schools. $125 million for each of FY2010 through FY2014; funds may be carried over for up to three fiscal years. Health professions schools, academic health centers, state or local governments, or other public or nonprofit entities participating in training activities. $5 million for each of FY2010 through FY2014, and SSAN for each subsequent fiscal year. FY2010 funding = $33 million; FY2011 funding = $33 million. [CFDA 93.107, 93.824] 5403(b) CRS-14 New PHSA Sec. 752 (HRSA) Continuing educational support for health professionals serving in underserved communities. Requires the Secretary to award grants to enhance education through distance learning, continuing education, collaborative conferences, and telehealth, with a focus on primary care. [CFDA 93.189] Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) ACA Section New/Existing Authority (Agency) Summary of Provision and Funding (FY2010-FY2011) Eligibility Authorization of Appropriations Mental and Behavioral Health 5306 Redesignates PHSA Sec. 756 as Sec. 757, and adds a new Sec. 756 (HRSA) Mental and behavioral health education and training grants. Authorizes grants for the recruitment and education of students in social work, interdisciplinary psychology training, and internships or other field placement programs related to child and adolescent mental health. Priority for social work grants given to schools of social work meeting certain criteria such as recruiting from and placing graduates into areas with a high-need and highdemand population. Priority for psychology grants given to institutions that focus on the needs of specified vulnerable groups. Priority for grants to train professional and paraprofessional child and adolescent mental health workers given to applicants that can, among other things, assess workforce needs and that have programs designed to increase the number of child and adolescent mental health workers serving high-priority populations. Historically black colleges and universities (HBCUs) or other minority-serving institutions. Institutions of higher education that have knowledge, understanding and participation of individuals and groups from different racial, ethnic, cultural, geographic, religious, linguistic, and class backgrounds, and different genders and sexual orientations; and that have internship or other field placement programs that prioritize cultural and linguistic competency. State-licensed mental health organizations to train paraprofessional child and adolescent mental health workers. $35 million for the period of FY2010 through FY2013 ($8 million for training in social work, $12 million for training in graduate psychology, $10 million for training in professional child and adolescent mental health, and $5 million for training in paraprofessional child and adolescent mental health). FY2010 funding = $3 million, FY2011 funding = $3 million. [CFDA 93.189] Policy and Planning 5101 New authority National Health Care Workforce Commission. Establishes a 15-member commission focused on evaluating and meeting the need for health care workers in the United States. The commission is required to conduct studies, produce annual reports beginning in 2011, and make recommendations on high-priority topics related to the health care workforce. Not applicable. SSAN (no years specified). 5102 New authority (HRSA) State health care workforce development grants. Establishes a matching grants program for state partnerships to plan and implement activities leading to coherent and comprehensive health care workforce development strategies at the state and local levels. Planning grants of up to $150,000 are for up to one year and require a 15% match. Implementation grants are for up to two years (with up to one additional year of funding) and require a 25% match. A state workforce investment board that includes certain specified members. For planning grants, $8 million for FY2010, and SSAN for each subsequent fiscal year. For implementation grants, $150 million for FY2010, and SSAN for each subsequent fiscal year. FY2010 funding = $6 million from the PPHF; FY2011 funding = $0. [CFDA 93.509] CRS-15 Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) New/Existing Authority (Agency) ACA Section 5103 Amends and reauthorizes PHSA Sec. 761 (HRSA) Summary of Provision and Funding (FY2010-FY2011) Health care workforce program assessment. Requires the Secretary to establish a National Center for Health Care Workforce Analysis, award grants to support state and regional centers for health workforce analysis, and increase funding for longitudinal evaluations of specified individuals who have received education, training, or financial assistance from programs under PHSA Title VII. FY2010 funding = $3 million; FY2011 funding = $3 million. [Includes funding for Sec. 792 (health professions data) and Sec. 806 (nursing grant program data). CFDA 93.300] Eligibility State and regional centers for health workforce analysis: states, state workforce investment boards, public health or health professions schools, academic health centers, or appropriate public or private nonprofit entities. Authorization of Appropriations For the National Center, $7.5 million for each of FY2010 through FY2014; for state and regional centers, $4.5 million for each of FY2010 through FY2014; and for longitudinal evaluations, SSAN for FY2010 through FY2014. Sources: Table 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 by the health provisions in the Health Care and Education Reconciliation Act of 2010 (HCERA; P.L. 111-152). FY2010 and FY2011 funding amounts are taken from HRSA’s FY2011 operating plan, available at http://www.hhs.gov/asfr/ob/docbudget/2011operatingplan.html, and the agency’s FY2012 congressional budget justification document, available at http://www.hhs.gov/about/hhsbudget.html. a. The nursing education loan repayment program repays 60% of a registered nurse’s educational loans in return for a two-year commitment to work in a health care facility with a critical shortage of nurses. Participants may have an additional 25% of their loan repaid in exchange for one more year of service. The nurse scholarship program offer scholarships to individuals attending nursing school in exchange for at least two years working in a health care facility with a critical shortage of nurses. Together the two programs, authorized under PHSA Sec. 846, received $94 million in FY2010 and $93 million in FY2011. The authorization of appropriations for Sec. 846 expired at the end of FY2007 and was not reauthorized by ACA. b. The Department of Defense and Full-Year Continuing Appropriations Act, 2011 (P.L. 112-10, Div. B, Sec. 1828) prohibited the transfer of funds from the Public Health and Social Services Emergency Fund (PHSSEF) to support the U.S. Public Health Sciences Track. The PHSSEF is an HHS account administered by the Secretary. Congress has historically used the PHSSEF to provide one-time funding for non-routine activities. Each fiscal year, Congress appropriates amounts to the PHSSEF for specified purposes. ACA did not authorize or appropriate funds to the PHSSEF. CRS-16 Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) Table 3. ACA Discretionary Funding: Prevention and Wellness ACA Section New/Existing Authority (Agency) Authorization of Appropriations Summary of Provision and Funding (FY2010-FY2011) Eligibility New PHSA Secs. 229 (OS), 310A (CDC), 925 (AHRQ); new SSA Sec. 713 (HRSA); and new FFDCA Sec. 1011 (FDA). Reauthorizes PHSA Secs. 486(a) (NIH) and 501(f) (SAMHSA). Offices of Women’s Health. Establishes or reauthorizes offices of women’s health in OS, CDC, AHRQ, HRSA, FDA, NIH, and SAMHSA. Grants, agreements, or contracts may be awarded for activities of the OS office to establish an information center and coordinating committee. Activities of other offices include recommendations regarding grant-making through other agency accounts, not direct grant-making. OS grants, agreements, and contracts may be awarded to public and private entities, agencies, and organizations. For most offices, SSAN for each of FY2010 through FY2014. For NIH and SAMHSA offices, SSAN (no years specified). 4003 Amends PHSA Sec. 915(a) (AHRQ). New PHSA Sec. 399U (CDC). Clinical and community preventive services task forces. Reauthorizes and expands the authority for the U.S. Preventive Services Task Force (USPSTF) to review and recommend effective clinical preventive services. Provides explicit statutory authority for the existing Task Force on Community Preventive Services (TFCPS) to review and recommend effective community-based interventions. Not applicable. SSAN for each fiscal year to carry out the activities of the USPSTF and the TFCPS. 4004 New authority Education and outreach regarding prevention. Requires the Secretary to carry out various specified communications activities regarding health promotion and disease prevention, for common and serious chronic health problems. They include establishing, within one year of enactment, a national media campaign on health promotion and disease prevention. Mentions awarding contracts, but does not specify eligibility criteria. SSAN for each fiscal year; no more than $500 million total. 4102(a) New PHSA Secs. 399LL, 399LL-1, and 399LL-2 (CDC) Oral health activities. Requires CDC, subject to appropriations, to fund a five-year national oral health education campaign, and award grants for dental caries disease management programs, among other things. Community-based providers of dental services, including public or private entities. SSAN (no years specified). Community-Based Prevention 3509/3511 CRS-17 Funding for the OS Office on Women’s Health = $43 million for FY2010 and for FY2011. Funding for the NIH Office of Research on Women’s Health = $34 million for FY2010 and for FY2011. Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) ACA Section 4102(b) New/Existing Authority (Agency) Amends PHSA Sec. 317M(c) (CDC, HRSA) Authorization of Appropriations Summary of Provision and Funding (FY2010-FY2011) Eligibility School-based dental sealant program. Amends the existing school-based dental sealant grant program, which was discretionary, by requiring the Secretary to award grants to the 50 states and to Indian tribes for school-based dental sealant programs. Grants must be awarded to each of the 50 states and territories, and to Indians, Indian tribes, tribal organizations, and urban Indian organizations. Preference given to urban districts with high participation rates in school meals programs, and rural districts with high poverty levels (as defined). Authority expired at end of FY2005; ACA does not authorize new funding. Funding for all CDC’s oral health programs under Sec. 317M: FY2010 = $15 million; FY2011 = $15 million. 4102(c) Amends PHSA Sec. 317M by adding a new subsection (d) (CDC) Oral health infrastructure. Requires the Secretary to enter into cooperative agreements to establish oral health leadership and programs to improve oral health. States, territories, and tribal entities. SSAN for FY2010 through FY2014. 4102(d) New authority (CDC, AHRQ) Oral health surveillance. Requires the Secretary to expand the following surveillance systems to include more information on oral health: Pregnancy Risk Assessment Monitoring System (PRAMS); National Health and Nutrition Examination Survey (NHANES); National Oral Health Surveillance System (NOHSS); and Medical Expenditure Panel Survey (MEPS). Not applicable. SSAN (no years specified) for PRAMS; SSAN for each of FY2010 through FY2014 for NOHSS; no explicit authorization of appropriations for NHANES/MEPS expansion. 4201 New authority (CDC) Community transformation grants. Requires CDC to fund competitive grants for the implementation, evaluation, and dissemination of evidence-based community preventive health activities. State or local government agencies or nonprofit organizations, networks of community-based organizations, and Indian tribes. SSAN for each of FY2010 through FY2014. FY2011 funding = $145 million from the PPHF. [CFDA 93.531] 4202(a) New authority (CDC) Community wellness pilot program. Requires CDC to award grants for five-year pilot programs to provide community prevention interventions, screenings, and clinical referrals for individuals between 55 and 64 years of age. State or local health departments, and Indian tribes. SSAN for each of FY2010 through FY2014. 4204 Amends PHSA Sec. 317 and adds a new subsection (m) (CDC) Immunization programs. Provides explicit authority for states to purchase vaccines at prices negotiated by Secretary. Permanently reauthorizes state immunization grants. Requires new immunization demonstration grants. States, political subdivisions, and other public entities. SSAN for each of FY2010 through FY2014 for demonstration grants; SSAN (no years specified) for other authorities. CRS-18 Funding for the Sec. 317 vaccination program: FY2010 = $561 million; FY2011 = $589 million. [Note: FY2011 funding = $489 million in regular appropriations + $100 million from the PPHF. CFDA 93.268] Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) ACA Section New/Existing Authority (Agency) Summary of Provision and Funding (FY2010-FY2011) Eligibility Authorization of Appropriations 4206 Amends PHSA Sec. 330 by adding a new subsection (s) Individualized wellness plan demonstration program. Requires the Secretary to establish a pilot program in not more than 10 community health centers to test the impact of providing at-risk individuals who use the centers with individualized wellness plans. Community health centers. SSAN (no years specified). 4304 New PHSA Sec. 2821 (CDC) Epidemiology and laboratory capacity grants. Codifies existing grant program to strengthen national epidemiology, laboratory, and information management capacity for the response to infectious diseases and other conditions of public health importance. State, local, or tribal health departments, tribal jurisdictions, or academic centers that meet CDC-specified criteria. $190 million for each of FY2010 through FY2013 (at least $95 million for epidemiology, $60 million for information management, and $32 million for laboratories). 10334 Amends PHSA Sec. 1707 (OS) and PHSA Title IV (NIH) Offices of Minority Health. Elevates the existing OS Office of Minority Health and NIH National Center on Minority Health and Health Disparities (NCMHD); instructs the OS office to award grants and undertake other activities to improve minority health status; and gives the new NIH National Institute on Minority Health and Health Disparities (NIMHD) responsibility for minority health disparities research and other health disparities research at NIH. For OS office: public and nonprofit private entities, federal agencies, and organizations that are indigenous human resource providers in communities of color. For the NIH Institute, grantee eligibility criteria are not stipulated. SSAN for each of FY2011 through FY2016 for OS office. Funding for the NIMHD = $211 million for FY2010, and $210 million for FY2011. Funding for the OS Office of Minority Health = $56 million for FY2010 and for FY2011. 10407 New authority (CDC) Diabetes activities. Requires CDC to conduct several diabetes prevention activities including state assessments, vital statistics, physician education, and funding of an Institute of Medicine (IOM) report. Not applicable. SSAN (no years specified). 10411 New PHSA Secs. 399V-2 (CDC) and 425 (NIH) Congenital heart disease programs. Authorizes CDC to establish a National Congenital Heart Disease Surveillance System (NCHDSS), or to award one grant to establish such a system. Authorizes NIH to expand and coordinate research on congenital heart disease. NCHDSS grantee must be a public or private nonprofit entity with experience in congenital heart disease. NIH must consider the application of research to minority and medically underserved populations. SSAN for each of FY2011 through FY2015 for both the surveillance system and the expanded research program. 10412 Reauthorizes PHSA Sec. 312 (HRSA) Public access defibrillation programs. Reauthorizes a program of grants for public access defibrillation programs, including equipment purchase and training. States and political subdivisions, Indian tribes, and tribal organizations. $25 million for each of FY2003 through FY2014. FY2010 funding = $2.5 million; FY2011 funding = $236,000. CRS-19 Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) New/Existing Authority (Agency) ACA Section Summary of Provision and Funding (FY2010-FY2011) Eligibility Authorization of Appropriations 10413 New PHSA Sec. 399NN (OS, CDC) Young women’s breast health awareness. Among other things, requires CDC to conduct an education campaign and award grants for a media campaign regarding breast health in young women, and to conduct prevention research; requires the Secretary to award grants to provide education and assistance to young women diagnosed with breast disease. Media campaign grants; not stated. Assistance grants; organizations and institutions, priority to those that deal specifically with breast cancer and pre-neoplastic breast disease in young women. $9 million for each of FY2010 through FY2014. 10501(g) New PHSA Sec. 399V-3 (CDC) National diabetes prevention program. Among other things, requires the Secretary to award grants for community-based diabetes prevention program model sites. State or local health departments, tribal organizations, national networks of community-based nonprofits, academic institutions, or other entities as determined by the Secretary. SSAN for each of FY2010 through FY2014. Workplace wellness program grants. Requires the Secretary to award grants to eligible small employers to provide their employees with access to comprehensive workplace wellness programs. Employers of fewer than 100 employees (who work 25 or more hours per week) that do not already provide a wellness program. $200 million for the period of FY2011 through FY2015, to remain available until expended. Workplace Wellness 10408 New authority (CDC) [Note: For FY2011, $10 million was transferred from the PPHF to establish and evaluate workplace wellness programs. The funding announcement did not mention ACA Sec. 10408, nor were the funds limited to small employers.] Sources: Table 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 by the health provisions in the Health Care and Education Reconciliation Act of 2010 (HCERA; P.L. 111-152). FY2010 and FY2011 funding amounts are taken from the HHS agency FY2011 operating plans, available at http://www.hhs.gov/asfr/ob/docbudget/2011operatingplan.html, and the agency FY2012 congressional budget justification documents, available at http://www.hhs.gov/about/hhsbudget.html. CRS-20 Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) Table 4. ACA Discretionary Funding: Maternal and Child Health New/Existing Authority (Agency) New SSA Sec. 512 (HRSA) ACA Section 2952(b) Summary of Provision and Funding (FY2010-FY2011) Services to individuals with a postpartum condition. Authorizes grants to establish, operate and coordinate effective and cost-efficient systems for the delivery of essential services to individuals with, or at risk of, postpartum depression and their families. Eligibility Public or nonprofit private entities, state or local government public-private partnerships, recipients of Healthy Start grants, public or nonprofit private hospitals, community-based organizations, hospices, ambulatory care facilities, community health centers, migrant health centers, public housing, primary care centers, and homeless health centers. Authorization of Appropriations $3 million for FY2010, and SSAN for each of FY2011 and FY2012. Source: Table 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 by the health provisions in Health Care and Education Reconciliation Act of 2010 (HCERA; P.L. 111-152). Table 5. ACA Discretionary Funding: Health Care Quality ACA Section New/Existing Authority (Agency) Summary of Provision and Funding (FY2010-FY2011) Eligibility Authorization of Appropriations Quality Measure Development, Analysis, and Public Reporting 3013(a)&(c) New PHSA 931 (AHRQ) Quality measure development. Requires the Secretary, in consultation with AHRQ and CMS, to (1) identify gaps where no quality measures exist or where existing measures need improvement, updating or expansion consistent with the National Strategy for Quality Improvement; and (2) fund or enter into agreements with eligible entities for purposes of developing, improving, updating, or expanding quality measures in areas identified as gap areas. Entities with demonstrated expertise in measure development and evaluation, which have adopted processes that incorporate the views of measure users, as well as those assessed by the measures, into the development process. $75 million for each of FY2010 through FY2014, to remain available until expended. At least 50% of the amounts appropriated must be used pursuant to SSA Sec. 1890A(e), as added by ACA Sec. 3013(b). See below. 3013(b) Amends new SSA Sec. 1890A, as added by ACA Sec. 3014(b), by adding a new subsection (e) (CMS) Quality and efficiency measures development. Requires CMS, in consultation with AHRQ, through contracts, to develop quality and efficiency measures as determined appropriate for use under the SSA. Not specified. See ACA Sec. 3013(a)&(c) above. CRS-21 Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) ACA Section New/Existing Authority (Agency) Summary of Provision and Funding (FY2010-FY2011) Eligibility Authorization of Appropriations 3015 New PHSA Sec. 399II Collection and analysis of data for quality and resource use measures. Requires the Secretary to establish and implement an overall strategic framework to carry out the public reporting of performance information. Requires the Secretary to collect and aggregate consistent data on quality and resource use measures, and authorizes the Secretary to award grants or contracts for this purpose. Authorizes the Secretary to award grants or contracts to eligible entities to support new, or improve existing, efforts to collect and aggregate quality and resource use measures. Multi-stakeholder entities that coordinate methods and plans for the consistent reporting of summary quality and cost information and that are capable of submitting such summary data for a particular population and providers. Awards may only be made to entities that enable summary data that can be integrated and compared across multiple sources. SSAN for each of FY2010 through FY2014. 3015 New PHSA Sec. 399JJ Public reporting of performance information. Requires the Secretary to make available to the public, through standardized websites, performance information summarizing data on quality measures. The information must include clinical conditions to the extent such data is available and, where appropriate, be providerspecific and sufficiently disaggregated and specific to meet the needs of patients with different clinical conditions. Not applicable. SSAN for each of FY2010 through FY2014. Quality Improvement Research, Training, and Implementation 3501 New PHSA Sec. 933 (AHRQ) Health care delivery system research. Requires AHRQ to (1) identify, develop, evaluate, and disseminate innovative strategies for quality improvement practices in the delivery of health care services that represent best practice; (2) support research on health care delivery improvement and facilitate adoption of best practices; and (3) make the research findings available to the public; among other specified functions. Not specified. $20 million for FY2010 through FY2014. 3501/3511 New PHSA Sec. 934 (AHRQ) Quality improvement technical assistance and implementation. Requires AHRQ to award technical assistance grants (with a matching requirement) to entities that deliver health care to help them understand, adapt, and implement the models and practices identified by the research conducted by the agency. May be a health care provider, professional society, health care worker organization, Indian health organization, quality improvement organization, patient safety organization, local quality improvement collaborative, the Joint Commission, academic health center, university, physician-based research network, primary care extension program, or an IHS program; and must have demonstrated expertise in providing information and technical support and assistance to health care providers regarding quality improvement. SSAN (no years specified). CRS-22 Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) ACA Section New/Existing Authority (Agency) 3508/3511 New authority Summary of Provision and Funding (FY2010-FY2011) Eligibility Authorization of Appropriations Quality and patient safety training. Authorizes the Secretary to award demonstration grants (with a matching requirement) to eligible entities or consortia to develop and implement academic curricula that integrate quality improvement and patient safety into clinical education of health professionals. Health professional schools; schools of public health, social work, nursing, pharmacy or health care administration; institutions with a graduate medical education program. SSAN (no years specified). Health Care Coordination 3502/3511 New authority Community health team grants to support medical homes. Requires the Secretary to award grants to or enter into contracts with eligible entities to support community-based interdisciplinary, interprofessional health teams in assisting primary care practices. Funding must be used to establish the health teams and to provide capitated payments to the providers. States or state-designated entities; Indian tribes or tribal organizations. SSAN (no years specified). 3503/3511 New PHSA Sec. 935 (AHRQ) Medication therapy management (MTM) grants. Requires the Secretary, not later than May 1, 2010, to provide grants to support MTM services provided by licensed pharmacists that are targeted at patients who take four or more prescribed medications, take high-risk medications, have two or more chronic diseases, or have undergone a transition of care or other factors that are likely to create a high risk for medication-related problems. Entities that provide a setting appropriate for MTM services and that submit a plan for achieving long-term financial sustainability. SSAN (no years specified). 3506 New PHSA Sec. 936 (AHRQ) Program to facilitate shared decision making. Requires the Secretary, through a contract, to develop and identify standards for patient decision aids, to review patient decision aids, and develop a certification process for determining whether patient decision aids meet those standards. Further requires the Secretary to (1) award grants or contracts to develop, update, and produce patient decision aids, to test such materials to ensure they are balanced and evidence-based, and to educate providers on their use; and (2) to award grants for establishing Shared Decision Making Resource Centers to develop and disseminate best practices to speed adoption and effective use of patient decision aids and shared decision making. Also requires the Secretary to award grants to providers for the development and implementation of shared decision-making techniques. The standards and certification contract is to be awarded to the entity that holds the contract under SSA Sec. 1890 (currently the National Quality Forum). Eligible grantees are not specified. SSAN for FY2010 and each subsequent fiscal year. CRS-23 Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) ACA Section 3510 New/Existing Authority (Agency) Amends and reauthorizes PHSA Sec. 340A (HRSA) Authorization of Appropriations Summary of Provision and Funding (FY2010-FY2011) Eligibility Patient navigator program. Prohibits the Secretary from awarding a grant to an entity under this section unless the entity provides assurances that patient navigators recruited, assigned, trained, or employed using these grant funds meet certain minimum core proficiencies. A public or nonprofit private health center (including an FQHC), IHS facility, hospital, cancer center, rural health clinic, academic health center, or a nonprofit entity that partners or coordinates referrals with such a facility to provide patient navigator services. $3.5 million for FY2010, and SSAN for each of FY2011 through FY2015. FY2010 funding = $5 million; FY2011 funding = $5 million. [CFDA 93.191] 5405 New PHSA Sec. 399V-1 (AHRQ) Primary care extension program. Requires the Secretary to establish a Primary Care Extension Program to award state planning and implementation grants for Primary Care Extension Program State Hubs, consisting of the state health department and other specified entities. State hubs must contract with and provide grant funds to county and local entities to serve as Primary Care Extension Agencies that assist primary care providers in implementing patient-centered medical homes and develop and support primary care learning communities, among other functions. States or multistate entities. $120 million for each of FY2011 and FY2012, and SSAN for each of FY2013 and FY2014. 5604 New PHSA Sec. 520K (SAMHSA) Co-locating primary and specialty care in communitybased mental health settings. Requires the Secretary to fund demonstration projects for providing coordinated and integrated services to individuals with mental illness and co-occurring chronic diseases through the co-location of primary and specialty care services in community-based mental and behavioral health settings. Qualified community mental health programs. $50 million for FY2010, and SSAN for each of FY2011 through FY2014. 10333 New PHSA Sec. 340H Community-based collaborative care network program. Authorizes the Secretary to award grants to eligible entities to support community-based collaborative care networks (CCN). An eligible CCN is a consortium of health care providers with a joint governance structure that provides comprehensive coordinated and integrated health care services (as defined by the Secretary) for lowincome populations. CCNs must include a safety net hospital and all FQHCs in the community, as specified. SSAN for each of FY2011 through FY2015. CRS-24 Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) New/Existing Authority (Agency) ACA Section 10410 New PHSA Sec. 520B (SAMHSA) Summary of Provision and Funding (FY2010-FY2011) Centers of excellence for depression. Requires SAMHSA to award five-year grants (with a matching requirement) on a competitive basis to eligible entities to establish national centers of excellence for depression. One grantee is to be designated as the coordinating center and required to establish and maintain a national database. Centers of excellence may receive a grant of up to $5 million; the coordinating center may receive a grant of up to $10 million. Eligibility Institutions of higher education; public or private nonprofit research institutions. Authorization of Appropriations $100 million for each of FY2011 through FY2015, and $150 million for each of FY2016 through FY2020. Sources: Table 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 by the health provisions in the Health Care and Education Reconciliation Act of 2010 (HCERA; P.L. 111-152). FY2010 and FY2011 funding amounts are taken from HRSA’s FY2011 operating plan, available at http://www.hhs.gov/asfr/ob/docbudget/2011operatingplan.html, and the agency’s FY2012 congressional budget justification document, available at http://www.hhs.gov/about/hhsbudget.html. Table 6. ACA Discretionary Funding: Nursing Homes ACA Section New/Existing Authority (Agency) 6112 New authority National independent monitor demonstration program. Requires the Secretary, within one year of enactment, to implement a two-year demonstration to develop, test, and implement an independent monitoring program to oversee interstate and large intrastate chains of skilled nursing facilities (SNFs) and nursing facilities (NFs). Duties of the independent monitor are stipulated, but eligibility criteria are not. SSAN (no years specified); a monitored chain must contribute a portion of costs of the demonstration, as determined by the Secretary. 6114 New authority Culture change and information technology demonstration programs. Requires the Secretary, within one year of enactment, to award one or more competitive grants to support each of the following two three-year demonstration projects for SNFs and NFs: (1) develop best practices for culture change (i.e., patient-centric models of care); and (2) develop best practices for the use of health information technology. Facility-based settings. SSAN (no years specified). Summary of Provision and Funding (FY2010-FY2011) Eligibility Authorization of Appropriations Source: Table 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 by the health provisions in the Health Care and Education Reconciliation Act of 2010 (HCERA; P.L. 111-152). CRS-25 Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) Table 7. ACA Discretionary Funding: Health Disparities Data Collection New/Existing Authority (Agency) ACA Section Summary of Provision and Funding (FY2010-FY2011) Eligibility Authorization of Appropriations 4302(a) New PHSA Title XXXI and Sec. 3101 Health disparities data collection and analysis. Not later than two years after enactment, requires federally conducted and supported health programs and surveys, to the extent practicable, to collect and report data on race, ethnicity, sex, primary language, and disability status, as well as other demographic data on health disparities as deemed appropriate by the Secretary. Requires the Secretary to adopt standards for the measurement and collection of such data. Requires the Secretary to analyze the data collected on health disparities; provide for the public reporting and dissemination of the data and analyses; and safeguard the privacy of the information. [Note: On June 29, 2011, HHS announced new draft standards for collecting and reporting health disparities data, and announced plans to begin collecting health data on lesbian, gay, bisexual, and transgender (LGBT) populations. See http://www.hhs.gov/news/press/2011pres/06/20110629a.html.] Not applicable. SSAN for each of FY2010 through FY2014; however, data may not be collected unless funds are directly appropriated for such purpose. 5605 New authority Key national indicators. Establishes a Commission on Key National Indicators composed of eight members appointed by Congress. [Note: The Commission members were appointed in Dec. 2010. See http://www.stateoftheusa.org/content/commissionon-key-national-ind.php.] Requires the commission to contract with the National Academy of Sciences to review available public and private sector research on key national indicator set selection and determine how best to establish a key national indicator system, among other things. Mandates a Government Accountability Office (GAO) study of previous efforts by public, private, or foreign entities to develop best practices for a key national indicator system. [Note: GAO released its study in March 2011. See http://www.gao.gov/new.items/d11396.pdf.] National Academy of Sciences. $10 million for FY2010, and $7.5 million for each of FY2011 through FY2018, with amounts appropriated to remain available until expended. Source: Table 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 by the health provisions in the Health Care and Education Reconciliation Act of 2010 (HCERA; P.L. 111-152). CRS-26 Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) Table 8. ACA Discretionary Funding: Emergency Care New/Existing Authority (Agency) ACA Section Summary of Provision and Funding (FY2010-FY2011) Eligibility Authorization of Appropriations 3504(a) New PHSA Sec. 1204 (OS) Regional systems for emergency care. Requires the Assistant Secretary for Preparedness and Response to award at least four multi-year contracts or grants (with matching requirement) for pilot projects to improve regional coordination of emergency services. States (or a partnership of one or more states and one or more localities) and Indian tribes (or a partnership of one or more tribes). Priority given to entities that serve a medically underserved population. $24 million for each of FY2010 through FY2014 for PHSA Title XII Parts A and B (i.e., Secs. 1201-1222). 3504(b) New PHSA Sec. 498D (NIH, AHRQ, HRSA, CDC) Emergency medicine research. Requires the Secretary to expand and accelerate basic, translational, and service delivery research on emergency medical care systems and emergency medicine, including pediatric emergency medical care. Also requires the Secretary to support research on the economic impact of coordinated emergency care systems. Not specified. SSAN for each of FY2010 through FY2014. 3505(a) Amends and reauthorizes PHSA Secs. 1241-1245 (HRSA) Trauma care centers. Requires the Secretary to establish separate grant programs for trauma care centers to (1) help defray substantial uncompensated care costs, (2) further the core missions of trauma care centers, and (3) provide emergency relief to ensure the continued availability of trauma services. Qualified public nonprofit IHS, Indian tribal, and urban Indian trauma centers. $100 million for FY2009, and SSAN for each of FY2010 through FY2015. 3505(b) New PHSA Secs. 1281-1282 (HRSA) Trauma service availability grants. Requires the Secretary to award grants to states for the purpose of supporting trauma-related physician specialties and broadening access to and availability of trauma care services. Grants are awarded to states to fund (1) a public or nonprofit trauma center, (2) a safety net public or nonprofit trauma center, or (3) a hospital in an underserved area (as defined by the state) that seeks to establish new trauma services. States must use at least 40% of the amount awarded in a fiscal year for grants to safety net trauma centers. $100 million for each of FY2010 through FY2015. 5603 Amends and reauthorizes PHSA Sec. 1910 (HRSA) Children’s emergency medical services demonstration grants. Expands emergency services for children who need treatment for trauma or critical care by lengthening the period for demonstration grants to four years (with an optional fifth year). States or accredited schools of medicine. $25 million for FY2010, $26.3 million for FY2011, $27.6 million for FY2012, $28.9 million for FY2013, and $30.4 million for FY2014. FY2010 funding = $22 million; FY2011 funding = $22 million. [CFDA 93.127] Sources: Table 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 by the health provisions in the Health Care and Education Reconciliation Act of 2010 (HCERA; P.L. 111-152). FY2010 and FY2011 funding amounts are taken from HRSA’s FY2011 operating plan, available at http://www.hhs.gov/asfr/ob/docbudget/2011operatingplan.html, and the agency’s FY2012 congressional budget justification document, available at http://www.hhs.gov/about/hhsbudget.html. CRS-27 Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) Table 9. ACA Discretionary Funding: Elder Justice ACA Section 6703(a) New/Existing Authority (Agency) New SSA Sec. 2021 (OS) 6703(a) New SSA Sec. 2022 6703(a) New SSA Sec. 2024 6703(a) New SSA Sec. 2031 6703(a) New SSA Sec. 2041(a) 6703(a) New SSA Sec. 2041(b) 6703(a) New SSA Sec. 2041(c) CRS-28 Summary of Provision and Funding (FY2010-FY2011) Elder Justice Coordinating Council. Establishes an Elder Justice Coordinating Council to include the Secretary as chair and the U.S. Attorney General, as well as the head of each federal department or agency, identified by the chair, as having administrative responsibility or administering programs related to elder abuse, neglect, and exploitation. Advisory Board on Elder Abuse, Neglect, and Exploitation. Establishes an advisory board to create a short- and long-term multidisciplinary plan for development of the field of elder justice and to make recommendations to the Elder Justice Coordinating Council. Authorization of appropriations. Authorizes funding for new SSA Secs. 2021 (Coordinating Council), 2022 (Advisory Board), and 2023 (human subject protection guidelines for researchers). Forensic centers and expertise. Requires the Secretary to award grants to eligible entities to establish and operate stationary and mobile forensic centers and to develop forensic expertise pertaining to elder abuse, neglect, and exploitation. Incentives for LTC staffing. Requires the Secretary to award grants to carry out activities for individuals to train for, seek, and maintain employment providing direct care in LTC facilities; and to award grants to conduct programs that offer direct care employees continuing training and varying levels of certification. Certified EHR technology grant program. Authorizes grants to LTC facilities for specified activities that would assist such entities in offsetting costs related to purchasing, leasing, developing, and implementing certified electronic health record technology. Standards for transactions involving clinical data by LTC facilities. Requires the Secretary to adopt electronic standards for the exchange of clinical data by LTC facilities and, within 10 years, to have in place procedures to accept the optional electronic submission of clinical data by LTC facilities pursuant to such standards. Eligibility Not applicable. Authorization of Appropriations SSAN (no years specified). See also new SSA Sec. 2024 below. Not applicable. SSAN (no years specified). See also new SSA Sec. 2024 below. Not applicable. $6.5 million for FY2011, and $7.0 million for each of FY2012 through FY2014. $4 million for FY2011, $6 million for FY2012, and $8 million for each of FY2013 and FY2014. (1) Stationary forensic centers: four of the grants to institutions of higher education with demonstrated expertise in forensics or commitment to preventing or treating elder abuse. (2) Mobile forensic centers: six of the grants to appropriate entities. LTC facilities or community-based LTC entities as defined by the Secretary. LTC facilities. Not applicable. For new SSA Sec. 2041: $20 million for FY2011, $17.5 million for FY2012, and $15 million for each of FY2013 and FY2014. See above authorization of appropriations for SSA Sec. 2041. See above authorization of appropriations for SSA Sec. 2041. Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) New/Existing Authority (Agency) New SSA Sec. 2042(a) ACA Section 6703(a) 6703(a) New SSA Sec. 2042(b) 6703(a) New SSA Sec. 2042(c) 6703(a) New SSA Sec. 2043(a) 6703(a) New SSA Sec. 2043(b) 6703(b) New authority 6703(b) New authority 6703(c) New authority Summary of Provision and Funding (FY2010-FY2011) Adult protective service functions. Requires the Secretary to undertake various activities with respect to adult protective services, including providing funding, collecting and disseminating data on elder abuse, disseminating information on best practices and training, conducting research, and providing technical assistance to states and other entities. Grants to enhance provision of adult protective services. Requires the Secretary to award formula grants to enhance adult protective services programs provided by states and local governments. Adult protective services demonstration grants. Requires the Secretary to fund state demonstration programs for adult protective services that test methods to prevent and detect elder abuse. Long-term care ombudsman program grants. Requires the Secretary to award grants to improve the capacity of state LTC ombudsman programs to address abuse and neglect complaints, conduct pilot programs, and provide support for such programs. Ombudsman training programs. Requires the Secretary to establish programs to provide and improve ombudsman training with respect to elder abuse, neglect, and exploitation for national organizations and state LTC ombudsman programs. National Training Institute for Surveyors. Requires that the Secretary enter into a contract with an entity to establish and operate a National Training Institute for Federal and State Surveyors to provide and improve training of surveyors investigating allegations of abuse in programs and LTC facilities that receive payments under Medicare or Medicaid. Grants to state survey agencies. Requires the Secretary to award grants to state survey agencies that perform surveys of Medicare or Medicaid participating nursing facilities to design and implement complaint investigation systems. National nurse aide registry study and report. Requires the Secretary, in consultation with appropriate government agencies and private sector organizations, to conduct a study on establishing a national nurse aide registry and report on its findings. Eligibility Not applicable. Authorization of Appropriations $3 million for FY2011, and $4 million for each of FY2012 through FY2014. States and U.S. territories. $100 million for each of FY2011 through FY2014. States. $25 million for each of FY2011 through FY2014. Eligible entities with relevant expertise and experience in abuse and neglect in LTC facilities, or state LTC ombudsman programs. $5 million for FY2011, $7.5 million for FY2012, and $10 million for each of FY2013 and FY2014. $10 million for each of FY2011 through FY2014. Not specified. Not specified. $12 million for the period of FY2011 through FY2014. State agencies that perform surveys of nursing facilities. $5 million for each of FY2011 through FY2014. Not applicable. SSAN (no years specified) to carry out these activities, with funding not to exceed $500,000. Source: Table 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 by the health provisions in the Health Care and Education Reconciliation Act of 2010 (HCERA; P.L. 111-152). CRS-29 Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) Table 10. ACA Discretionary Funding: Biomedical Research ACA Section 10409 New/Existing Authority (Agency) Summary of Provision and Funding (FY2010-FY2011) Eligibility Amends PHSA Secs. 402(b) and 499(c); new PHSA Sec. 402C (NIH) Cures Acceleration Network (CAN). Establishes a CAN program within the Office of the NIH Director to award grants, contracts, or cooperative agreements to support the development of treatments for diseases or conditions that are rare, and for which market incentives are inadequate. Public or private entity, which may include a private or public research institution, an institution of higher education, a medical center, a biotechnology company, a pharmaceutical company, a disease advocacy organization, a patient advocacy organization, or an academic research institution. Authorization of Appropriations $500 million for FY2010, and SSAN for subsequent fiscal years. Other funds appropriated under the PHSA may not be allocated to CAN. Source: Table 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 by the health provisions in the Health Care and Education Reconciliation Act of 2010 (HCERA; P.L. 111-152). Table 11. ACA Discretionary Funding: Biologics New/Existing Authority (Agency) ACA Section 7002 Amends PHSA Sec. 351 (FDA) Summary of Provision and Funding (FY2010-FY2011) FDA approval of follow-on biologics. Creates a regulatory pathway for approving biosimilar or interchangeable biological drugs. Provides for the collection of user fees, subject to congressional authorization, to cover regulatory costs beginning in FY2013. Eligibility Not applicable. Authorization of Appropriations SSAN for each of FY2010 through FY2012. Source: Table 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 by the health provisions in the Health Care and Education Reconciliation Act of 2010 (HCERA; P.L. 111-152). CRS-30 Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) Table 12. ACA Discretionary Funding: 340B Drug Pricing New/Existing Authority (Agency) ACA Section 7102 Amends PHSA Sec. 340B(d) (HRSA) Summary of Provision and Funding (FY2010-FY2011) Improvements to 340B program integrity. Requires the Secretary to develop systems to improve compliance and program integrity to (1) increase transparency and strengthen monitoring, oversight, and investigation of the prices that manufacturers charge covered entities; and (2) ensure covered entities do not divert drugs or obtain multiple discounts. Further requires the Secretary to establish a new administrative dispute resolution process to mediate and resolve covered entity overpayment claims and manufacturer claims against covered entities for drug diversion or multiple discounts. Eligibility Not applicable. Authorization of Appropriations SSAN for FY2010 and each succeeding fiscal year. FY2010 funding = $2 million; FY2011 funding = $4 million. Sources: Table 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 by the health provisions in the Health Care and Education Reconciliation Act of 2010 (HCERA; P.L. 111-152). FY2010 and FY2011 funding amounts are taken from HRSA’s FY2011 operating plan, available at http://www.hhs.gov/asfr/ob/docbudget/2011operatingplan.html, and the agency’s FY2012 congressional budget justification document, available at http://www.hhs.gov/about/hhsbudget.html. Table 13. ACA Discretionary Funding: Medical Malpractice New/Existing Authority (Agent) ACA Section 10607 New PHSA Sec. 399V-4 (HRSA) Summary of Provision and Funding (FY2010-FY2011) Liability reform demonstration program. Authorizes five-year demonstration grants to states for the implementation and evaluation of alternatives to current tort litigation for resolving disputes over injuries allegedly caused by health care providers or organizations. Planning grants of up to $500,000 may be awarded to states for the development of demonstration project applications. Eligibility To receive a grant, a state must develop an alternative system that allows for the resolution of disputes caused by health care providers or organizations, and reduces medical errors by encouraging the collection and analysis of patient safety data related to the resolved disputes. Authorization of Appropriations $50 million for the period FY2011 through FY2015. Source: Table 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 by the health provisions in the Health Care and Education Reconciliation Act of 2010 (HCERA; P.L. 111-152). CRS-31 Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) Table 14. ACA Discretionary Funding: Pain Care Management ACA Section New/Existing Authority (Agency) 4305(a) New authority Summary of Provision and Funding (FY2010-FY2011) Conference on pain. Requires the Secretary, within one year of appropriating funds, to contract with the IOM to convene a Conference on Pain for the purpose of assessing the public health impact of pain, reviewing pain research, care, and education, and identifying barriers to improved pain care. A report summarizing the Conference’s findings must be submitted to Congress by June 30, 2011. [Note: IOM released its report on June 29, 2011. See http://painconsortium.nih.gov/.] Eligibility IOM or another appropriate entity if the IOM declines. Authorization of Appropriations SSAN for each of FY2010 and FY2011. Source: Table 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 by the health provisions in the Health Care and Education Reconciliation Act of 2010 (HCERA; P.L. 111-152). Table 15. ACA Discretionary Funding: Medicaid Demonstrations New/Existing Authority (Agency) ACA Section Summary of Provision and Funding (FY2010-FY2011) Eligibility Authorization of Appropriations 2705 New authority (CMS) Global payment system demonstration program. Requires the Secretary, in coordination with the Center for Medicare and Medicaid Innovation, to fund up to five demonstrations during the period FY2010 through FY2012 under which a participating state will adjust payments made to an eligible hospital system or network from a fee-for-service model to a global capitated payment model. Large safety net hospital systems or networks. SSAN (no years specified). 2706 New authority (CMS) Pediatric accountable care organization demonstration program. Requires the Secretary to conduct a five-year demonstration (Jan. 1, 2012 through Dec. 31, 2016) under which a participating state is allowed to recognize pediatric providers as an accountable care organization (ACO) for the purpose of receiving incentive payments. Eligible pediatric providers must meet certain performance guidelines established by the Secretary to be recognized as an ACO, and must achieve a specified minimum level of Medicaid savings to receive an incentive payment. SSAN (no years specified). Source: Table 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 by the health provisions in the Health Care and Education Reconciliation Act of 2010 (HCERA; P.L. 111-152). CRS-32 Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) Table 16. ACA Discretionary Funding: Medicare New/Existing Authority (Agency) ACA Section 3129 Amends and reauthorizes SSA Sec. 1820 (HRSA) Summary of Provision and Funding (FY2010-FY2011) Rural hospital flexibility grant program. Extends authorization of appropriations for the rural hospital flexibility (FLEX) grants that support a range of performance and quality improvement activities at small rural hospitals. Permits the funding to be used to help rural hospitals participate in delivery system reform programs authorized under ACA. Eligibility States; small rural hospitals. Authorization of Appropriations SSAN for each of FY2011 and FY2012, to remain available until expended. FY2010 funding = $41 million; FY2011 funding = $41 million. Sources: Table 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 by the health provisions in the Health Care and Education Reconciliation Act of 2010 (HCERA; P.L. 111-152). FY2010 and FY2011 funding amounts are taken from HRSA’s FY2011 operating plan, available at http://www.hhs.gov/asfr/ob/docbudget/2011operatingplan.html, and the agency’s FY2012 congressional budget justification document, available at http://www.hhs.gov/about/hhsbudget.html. Table 17. ACA Discretionary Funding: Private Health Insurance New/Existing Authority (Agency) ACA Section 1334 New authority (OPM) Summary of Provision and Funding (FY2010-FY2011) Multi-state health plans. Requires OPM to contract with health insurers to offer at least two multi-state health plans (at least one nonprofit) through exchanges in each state. Authorizes OPM to prohibit multi-state plans that do not meet standards for medical loss ratios, profit margins, and premiums. Requires multi-state plans to cover essential health benefits and meet all the requirements of a qualified health plan. Eligibility Health insurance issuers that agree to offer multi-state qualified health plans and meet other specified requirements. Authorization of Appropriations SSAN (no years specified). Source: Table 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 by the health provisions in the Health Care and Education Reconciliation Act of 2010 (HCERA; P.L. 111-152). CRS-33 Discretionary Funding in the Patient Protection and Affordable Care Act (ACA) Author Contact Information C. Stephen Redhead, Coordinator Specialist in Health Policy credhead@crs.loc.gov, 7-2261 Sarah A. Lister Specialist in Public Health and Epidemiology slister@crs.loc.gov, 7-7320 Kirsten J. Colello Specialist in Health and Aging Policy kcolello@crs.loc.gov, 7-7839 Amanda K. Sarata Specialist in Health Policy asarata@crs.loc.gov, 7-7641 Elayne J. Heisler Analyst in Health Services eheisler@crs.loc.gov, 7-4453 Acknowledgments Pamela W. Smith, Analyst in Biomedical Policy, provided extensive comments on the initial version of this report. Key Policy Staff Area of Expertise Health Centers and Clinics Health Care Workforce Long-Term Care Prevention and Wellness Maternal and Child Health Health Care Quality Nursing Homes Health Disparities Emergency Care Elder Justice Biomedical Research Biologics 340B Drug Pricing Medical Malpractice Pain Care Management Medicaid Medicare Private Health Insurance Congressional Research Service Name Elayne J. Heisler C. Stephen Redhead Elayne J. Heisler Bernice Reyes-Akinbileje Kirsten J. Colello Sarah A. Lister Emilie Stoltzfus Amalia Corby-Edwards Amanda K. Sarata Cliff Binder Amalia Corby-Edwards Elayne J. Heisler Kirsten J. Colello Pamela W. Smith Judith A. Johnson Cliff Binder Vivian S. Chu Kirsten J. Colello Cliff Binder Sibyl Tilson Bernadette Fernandez Phone 7-4453 7-2261 7-4453 7-2260 7-7839 7-7320 7-2324 7-0423 7-7641 7-7965 7-0423 7-4453 7-7839 7-7048 7-7077 7-7965 7-4576 7-7839 7-7965 7-7368 7-0322 E-mail eheisler@crs.loc.gov credhead@crs.loc.gov eheisler@crs.loc.gov breyes@crs.loc.gov kcolello@crs.loc.gov slister@crs.loc.gov estoltzfus@crs.loc.gov acorbyedwards@crs.loc.gov asarata@crs.loc.gov cbinder@crs.loc.gov acorbyedwards@crs.loc.gov eheisler@crs.loc.gov kcolello@crs.loc.gov psmith@crs.loc.gov jajohnson@crs.loc.gov cbinder@crs.loc.gov vchu@crs.loc.gov kcolello@crs.loc.gov cbinder@crs.loc.gov stilson@crs.loc.gov bfernandez@crs.loc.gov 3411 The Health Care and Education Reconciliation Act (HCERA) established, and appropriated $1 billion to, the Health Insurance Reform Implementation Fund (HIRIF)—one of many sources of mandatory funding for ACA programs and activities (see discussion below under “Mandatory (...continued) Health Care Legislation Enacted in March 2010,” Statement of Douglas W. Elmendorf, Director, 112th Cong., 1st sess., March 30, 2011. Available at http://www.cbo.gov/ftpdocs/121xx/doc12119/03-30-HealthCareLegislation.pdf. See p. 16. CBO’s estimate of ACA discretionary spending includes (1) amounts specified in ACA, plus estimated amounts for subsequent years (adjusted for anticipated inflation) where ACA specified an amount for the first year (FY2010 or FY2011) and authorized SSAN for subsequent years; and (2) estimated amounts for subsequent years (adjusted for anticipated inflation) where there is an appropriation for FY2010 under prior law and ACA authorized the appropriation of SSAN for later years. The CBO estimate does not include new ACA programs for which the law provided only an authorization for the appropriation of SSAN. 10 Examples include CDC’s congenital heart disease and breast health awareness programs (see Table 3) and the Cures Acceleration Network (CAN) program at NIH (see Table 10). 11 CBO, May 11, 2010, see footnote 9. Congressional Research Service 4 Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) Appropriations in ACA”).12 HIRIF funds are for administrative expenses associated with implementing the new law. While HHS is using the HIRIF to cover its own ACA administrative costs, a significant portion of HIRIF funding has been transferred to the IRS. HHS projects that all the HIRIF funds will have been obligated by the end of FY2012. Thereafter, ACA administrative costs will have to be funded through annual discretionary appropriations. The President’s FY2013 budget requested more than $1 billion in new discretionary funding for HHS and the IRS to pay for ongoing administrative costs associated with ACA implementation. It remains unclear whether congressional appropriators will provide any or all of those funds in FY2013. Congress has yet to complete action on any of the FY2013 appropriations bills and has instead passed, and the President has signed, a continuing resolution (H.J.Res. 117) to provide temporary funding authority for the first six months of FY2013. The requested ACA administrative funding was not included in H.J.Res. 117.13 Mandatory Appropriations in ACA Separate from the discretionary spending authorizations summarized in the tables in this report, ACA included numerous mandatory appropriations that provide billions of dollars to fund new and existing grant programs and activities within HHS.14 Of particular note, ACA established two multi-billion dollar funds that are helping support several of the discretionary grant programs authorized (or reauthorized) under ACA: • The Community Health Center Fund (CHCF) will provide a total of $11 billion over the period FY2011-FY2015 for the federal health centers program and the National Health Service Corps (NHSC).15 While CHCF funds have so far been used to supplement annual discretionary appropriations for the health centers program, the NHSC program received no discretionary funding for FY2012 and is relying entirely on CHCF funds (see Table 1 and Table 2). Note: A separate ACA appropriation provided $1.5 billion for health center construction and renovation (see Table 1).16 • The Prevention and Public Health Fund (PPHF), for which ACA provided a permanent annual appropriation, is intended to fund prevention, wellness, and 12 HCERA Section 1105; see footnote 1. The Continuing Appropriations Resolution, 2013 (P.L. 112-175, 126 Stat. 1313), funds government operations at an annualized rate of $1.047 trillion in discretionary budget authority, 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. P.L. 112-175 does not incorporate any of the new ACA-related policies or funding that were included in the President’s FY2013 budget. 14 All these mandatory spending provisions are summarized in a companion product, CRS Report R41301, Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act (PPACA), by C. Stephen Redhead. 15 ACA Section 10503(a)-(b). The CHCF provides the following amounts for health center operating grants: FY2011 = $1 billion; FY2012 = $1.2 billion; FY2013 = $1.5 billion; FY2014 = $2.2 billion; and FY2015 = $3.6 billion. It also provides the following amounts for the National Health Service Corps: FY2011 = $290 million; FY2012 = $295 million; FY2013 = $300 million; FY2014 = $305 million; and FY2015 = $310 million. 16 ACA Section 10503(c). 13 Congressional Research Service 5 Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) other public health-related programs and activities authorized under the PHSA.17 PPHF funds have been used to support at least six new discretionary grant programs authorized under ACA.18 In addition, PPHF funds are supplementing, and in some cases supplanting, annual discretionary appropriations for several established programs that were reauthorized by the law (see Table 2, Table 3, and Table 5). Impact of Spending Cuts Under the Budget Control Act On January 2, 2013, pursuant to the Budget Control Act of 2011 (BCA), the President will order across-the-board spending cuts—a process known as sequestration—for all nonexempt direct and discretionary spending programs, unless Congress and the President enact legislation to modify or repeal the BCA. As discussed below, a FY2013 sequestration would significantly impact ACA discretionary spending. 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.19 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.20 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 17 ACA Section 4002. As originally enacted, ACA appropriated the following amounts to the PPHF: FY2010 = $500 million; FY2011 = $750 million; FY2012 = $1 billion; FY2013 = $1.25 billion; FY2014 = $1.5 billion; and FY2015 and each fiscal year thereafter = $2 billion. The Middle Class Tax Relief and Job Creation Act of 2012 (P.L. 112-96, Sec. 3205) amended Section 4002 and reduced the amounts appropriated over the period FY2013-FY2021 by a total of $6.25 billion. The reduced appropriations for each of those fiscal years are as follows: FY2013 = $1 billion; FY2014 = $1 billion; FY2015 = $1 billion; FY2016 = $1 billion; FY2017 = $1 billion; FY2018 = $1.25 billion; FY2019 = $1.25 billion; FY2020 = $1.5 billion; and FY2021 = $1.5 billion. 18 Those programs include (1) Sec. 5208, Nurse-Managed Health Clinics, see Table 1; (2) Sec. 5306, Mental and Behavioral Health Education and Training Grants, see Table 2; (3) Sec. 5102, State Health Care Workforce Development Grants, see Table 2; (4) Sec. 4201, Community Transformation Grants, see Table 3; (5) Sec. 10408, Small Business Workplace Wellness Grants, see Table 3; and (6) Sec. 10501(g), National Diabetes Prevention Program, see Table 3. 19 P.L. 112-25, 125 Stat. 240. 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. The President has exercised the authority provided him in the BCA and raised the debt ceiling by a total of $2.1 trillion, from $14.294 trillion to $16.394 trillion. 20 U.S. Congressional Budget Office, Analysis of Budget Control Act, August 1, 2011. Available at http://www.cbo.gov/publication/41626. Congressional Research Service 6 Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) 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. The November 21, 2011, announcement by the Joint Committee that it was unable to agree on a deficit-reduction bill means that automatic spending reductions totaling $1.2 trillion are all but certain to take effect, absent the enactment of new legislation to modify or repeal the BCA. Based on the formula in the BCA, the automatic spending reductions would cut the same amount—$54.7 billion—from both defense and nondefense spending for each fiscal year over the period FY2013-FY2021. The annual spending reduction in each category—defense and nondefense—would be divided proportionately between discretionary spending and nonexempt direct spending. In FY2013, both the discretionary and the direct spending reductions would be achieved through sequestration—a largely across-the-board 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.21 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.22 For each of the remaining fiscal years (i.e., FY2014-FY2021), however, 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 is to occur on January 2, 2013. The sequestrations for subsequent fiscal years are to occur at the time of the President’s annual budget submission in early February. FY2013 Nondefense Discretionary 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.23 The OMB report provides a breakdown of exempt and nonexempt budget accounts, and includes estimates of the FY2013 funding reductions in nonexempt accounts. OMB calculated that sequestration would 21 For more information, see CRS Report R42050, Budget “Sequestration” and Selected Program Exemptions and Special Rules, coordinated by Karen Spar. 22 Ibid. Note that all veterans programs, mandatory and discretionary, are exempt from sequestration. 23 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. Congressional Research Service 7 Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) result in an 8.2% reduction in nonexempt nondefense discretionary spending. That reduction would generally apply to the discretionary spending summarized in the tables in this report.24 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.”25 Importantly, the reductions in nondefense (and defense) discretionary spending under the BCA would largely occur in the first year (i.e., FY2013) through sequestration, rather than phasing in gradually over the entire period. In each subsequent fiscal year (i.e., FY2014-FY2021), the level of nondefense (and defense) discretionary spending would be tied to the adjusted (i.e., lowered) cap, which would actually grow by about 2% annually over that period. 24 For more discussion and analysis of the potential impact of spending reductions triggered by the BCA, see CRS Report R42051, Budget Control Act: Potential Impact of Sequestration on Health Reform Spending, by C. Stephen Redhead. 25 Ibid., p. 1. Congressional Research Service 8 Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) Table 1. ACA Discretionary Spending: Health Centers and Clinics ACA Section Statutory Authority (Agency) Summary of Provision Authorization of Appropriations Funding (FY2011-FY2013) Health Centers: Existing Program 5601 Reauthorizes PHSA Sec. 330 (HRSA) Health centers. Permanently reauthorizes funding for the program that provides operating grants to health centers serving federally designated medically underserved populations and furnishing comprehensive primary care services, referrals, and other services needed to facilitate access to such care, regardless of ability to pay. Eligible grantees include community, migrant, public housing, and homeless health centers that meet the statutory requirements of PHSA Sec. 330. $3.0 billion for FY2010, $3.9 billion for FY2011, $5.0 billion for FY2012, $6.5 billion for FY2013, $7.3 billion for FY2014, and $8.3 billion for FY2015; amounts in subsequent years based on previous year’s funding, subject to adjustment. FY2011 funding = $2.6 billion (includes $1.0 billion from the CHCF), FY2012 funding = $2.8 billion (includes $1.2 billion from the CHCF), FY2013 request = $3.1 billion (includes $1.5 billion from the CHCF).a [CFDA 93.224, 93.527] Note: ACA Sec. 10503(c) appropriated $1.5 billion for the period FY2011 through FY2015 for health center construction and renovation; see CRS Report R41301. Health Centers and Clinics: New Programs 4101(b) 5208 CRS-9 New PHSA Sec. 399Z-1 (HRSA) School-based health centers (SBHCs). Requires the Secretary to award grants to fund the management and operation of SBHCs that provide comprehensive physical and behavioral health services to children and adolescents, subject to parental consent. SBHCs that meet certain specified criteria and match 20% of the grant amount with nonfederal funds (unless waived). Preference may be given to SBHCs serving children and adolescents who have limited access to or difficulty accessing health care. SSAN for each of FY2010 through FY2014. New PHSA Sec. 330A-1 (HRSA) Nurse-managed health clinics (NMHCs). Requires the Secretary to award grants to fund the operation of NMHCs—associated with schools, colleges, federally qualified health centers (FQHCs), or nonprofit health/social services agencies—that provide comprehensive primary health care and wellness services to vulnerable or underserved populations regardless of income or insurance status. At least one advanced practice nurse must hold an executive management position in the NMHC. $50 million for FY2010, and SSAN for each of FY2011 through FY2014. Note: ACA Sec. 4101(a) appropriated a total of $200 million for SBHC construction and renovation; see CRS Report R41301. Note: This new program received $15 million in FY2010 funds from the PPHF but has not received any funding since that time. [CFDA 93.515] Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) Statutory Authority (Agency) ACA Section 10504 New authority (HRSA) Summary of Provision Access to affordable care demonstration program. Within six months of enactment, requires the Secretary to establish a three-year demonstration project in up to 10 states—each state may receive up to $2 million—to provide access to comprehensive health care services to the uninsured. Eligible grantees must be state-based, nonprofit, publicprivate partnerships that provide access to comprehensive health care services to the uninsured at reduced fees. Authorization of Appropriations Funding (FY2011-FY2013) SSAN (no years specified). Sources: Table 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). FY2011, FY2012 and requested FY2013 funding amounts are taken from HRSA’s FY2013 budget justification document for Congress, available at http://www.hrsa.gov/ about/budget/index.html. a. Annual funding totals for health centers include the following amounts for the Federal Tort Claims Act (FTCA) program: FY2011 = $100 million; FY2012 = $95 million; FY2013 request = $95 million. Under the FTCA, health center employees and contractors are considered federal employees immune from medical malpractice lawsuits while acting within the scope of their employment. The federal government assumes responsibility for such malpractice claims. Table 2. ACA Discretionary Spending: Health Care Workforce ACA Section Statutory Authority (Agency) Summary of Provision Authorization of Appropriations Funding (FY2011-FY2013) National Health Service Corps (NHSC) 5207 CRS-10 Reauthorizes PHSA Title III, Part D, Subpart III (HRSA) NHSC scholarships and loan repayments. Permanently reauthorizes funding for the NHSC program. In exchange for a commitment to work in a federally designated Health Professional Shortage Area (HPSA), the program provides (1) scholarships to students training in a primary care discipline to cover tuition, fees, other educational costs, and a stipend; and (2) student loan repayments of up to $50,000 a year to primary care and mental health clinicians. To be eligible for a scholarship, a student must be accepted or enrolled in a training program for medicine, dentistry, family nurse practitioner, nurse midwife, or physician assistant, and agree to two to four years of service in an NHSC-approved site in a HPSA. Loan repayments are for primary care, dental, and mental health clinicians who agree to at least two years of service in an NHSC-approved site in a HPSA. $320 million for FY2010, $414 million for FY2011, $535 million for FY2012, $691 million for FY2013, $893 million for FY2014, and $1,155 billion for FY2015; amounts in subsequent years based on previous year’s funding, subject to adjustment. FY2011 funding = $315 million (includes $290 million from the CHCF), FY2012 funding = $295 million (all CHCF), FY2013 request = $300 million (all CHCF). [CFDA 93.162, 93.288, 93.547] Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) ACA Section Statutory Authority (Agency) Summary of Provision Authorization of Appropriations Funding (FY2011-FY2013) Physicians: Existing Program 5301 Amends and reauthorizes PHSA Sec. 747 (HRSA) Primary care training and enhancement program. (1) Authorizes five-year grants to public and nonprofit private hospitals, medical schools, academically affiliated physician assistant training programs, and other public and nonprofit private entities to support training programs in primary care. Funds are to be used to plan, develop and operate accredited training programs, including residency and internship programs, in family medicine, general internal medicine, and general pediatrics and to provide financial assistance (e.g., traineeships). (2) Authorizes five-year grants to medical schools for primary care capacity building. Funds are to be used to create academic units or programs that improve clinical teaching in the primary care fields, and (in a separate authorization) to integrate academic units to enhance interdisciplinary recruitment, training, and faculty development. Funding priority given to entities proposing innovative approaches to primary care training and with a record of training primary care providers, among other things. For both grant programs, $125 million for FY2010, and SSAN for each of FY2011 through FY2014. Note: 15% of the amount appropriated must be use for physician assistant training programs. Pediatric specialist loan repayment program. Requires the Secretary to implement a loan repayment program that pays up to $35,000 for each year of service (for a maximum of three years) to practicing or in-training pediatric specialists and surgeons, as well as child and adolescent mental health specialists, who agree to at least two years of service in a HPSA. $30 million for each of FY2010 through FY2014 for loan repayments to pediatric specialists and surgeons; $20 million for each of FY2010 through FY2013 for loan repayments to mental health providers. A separate authorization of $750,000 for each of FY2010 through FY2014 is provided for capacity building grants to integrate academic units. FY2011 funding = $39 million, FY2012 funding = $39 million, FY2013 request = $51 million. [CFDA 93.510, 93.514, 93.884] Note: For FY2010, this program received $198 million in PPHF funds in addition to its annual discretionary appropriation of $39 million. Physicians: New Programs 5203 New PHSA Sec. 775 (HRSA) FY2013 request = $5 million. 5508(a) New PHSA Sec. 749A (HRSA) Teaching health centers development grants. Authorizes threeyear grants of up to $500,000 to FQHCs, rural health clinics, Indian health centers, and entities receiving PHSA Title X (family planning) funds that establish or expand a primary care residency training program. $25 million for FY2010, $50 million for each of FY2011 and FY2012, and SSAN for each fiscal year thereafter. 10501(l) New PHSA Sec. 749B (HRSA) Rural physician training grants. Requires the Secretary to (1) award grants medical schools for recruiting students most likely to practice in underserved rural communities and for providing rural-focused training and experience; and (2) within 60 days of enactment, by regulation, define underserved rural communities. Priority is given to entities that train students to practice in rural communities, that have established partnerships with rural community health centers, or who submit a longterm plan for tracking where graduates practice. [Note: HRSA published an interim final rule on May 26, 2010 (75 Federal Register 29447).] $4 million for each of FY2010 through FY2013. CRS-11 Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) ACA Section Statutory Authority (Agency) Summary of Provision Authorization of Appropriations Funding (FY2011-FY2013) Dentistry: Existing Program 5303 New PHSA Sec. 748; authority previously part of Sec. 747 (HRSA) General, pediatric, and public health dentistry training. Authorizes grants or contracts to dental and dental hygiene schools, as well as approved residency or advanced education programs in general, pediatric, or public health dentistry, for dental training activities including faculty development, financial assistance, faculty loan repayment programs, technical assistance for pediatric dental programs, and preand post-doctoral training programs in dental primary care. Gives priority to entities that train individuals from disadvantaged backgrounds, who have a record of placing graduates in facilities that provide care to the underserved, or whose programs focus on providing care to the underserved through demonstrated partnerships with FQHCs, rural health clinics, or through having programs focused on specific topics, such as HIV/AIDs. $30 million for FY2010, and SSAN for each of FY2011 through FY2015; permits grantees to carry over funds for up to three fiscal years. Alternative dental health care provider demonstration program. Authorizes the Secretary to award 15 five-year grants of not less than $4 million to train or employ alternative dental health care providers (e.g., community dental health coordinators, dental health aides) to increase access to dental health care services in rural and other underserved communities. Eligible grantees include institutions of higher education; public-private entities; FQHCs; facilities operated by the IHS or by Indian tribes or organizations; state or county public health clinics; public hospitals or health systems; and accredited dental education programs. SSAN (no years specified). FY2011 funding = $17 million, FY2012 funding = $20 million, FY2013 request = $20 million. [CFDA 93.059, 93.884] Note: HRSA also administers a state oral health workforce grant program (PHSA Sec. 340G): FY2011 funding = $16 million, FY2012 funding = $12 million, FY2013 request = $11 million. [CFDA 93.236] Dentistry: New Program 5304 CRS-12 New PHSA Sec. 340G-1 (HRSA) FY2013 request = $1 million. Note: The Consolidated Appropriations Act, 2012 (P.L. 112-74) prohibited HRSA funding for this new program in FY2012. Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) ACA Section Statutory Authority (Agency) Summary of Provision Authorization of Appropriations Funding (FY2011-FY2013) Nursing: Existing Programs 5309(a) 5311(a) 5312 Amends and reauthorizes PHSA Sec. 831 (HRSA) Nurse education, practice, quality, and retention program. Authorizes grants or contracts to expand enrollment in baccalaureate nursing programs; provide training in new technologies; develop cultural competencies; expand nursing practice arrangements in non-institutional settings; and support nurse retention programs that offer career advancement for nursing personnel, enhance collaboration among nurses and other health professionals, and promote nurse involvement in clinical decision making. Eligible grantees include nursing schools, health care facilities (including NMHCs), or partnerships of the two. SSAN for each of FY2010 through FY2014. See also ACA Sec. 5312 below, which reauthorized appropriations for several Title VIII nursing education programs, including Sec. 831. Amends and reauthorizes PHSA Sec. 846A (HRSA) Nursing faculty loan program. Authorizes loans to nursing school students pursuing advanced degrees to become qualified nursing faculty. Sets the annual loan limit at $35,500 for FY2010 and FY2011; for subsequent fiscal years, the loan limit is subject to a cost-of-attendance adjustment. Students who go on to serve as nursing school faculty may have up to 85% of their loan repayment cancelled. SSAN for each of FY2010 through FY2014. Amends PHSA Sec. 871; previously Sec. 841 (HRSA) Authorization of appropriations. Reauthorizes funding for the following PHSA Title VIII nursing workforce programs: For PHSA Secs. 811, 821, 831, and new 831A (see ACA Sec. 5309(b) below), $338 million for FY2010, and SSAN for each of FY2011 through FY2016. 1. Advanced nursing education (PHSA Sec. 811) – grants to accredited programs for advanced nurse education including combined registered nurse masters degree programs, authorized nurse practitioner programs, accredited nurse midwifery programs, and accredited nurse anesthesia programs. 2. Nursing workforce diversity (PHSA Sec. 821) – grants to nursing schools, academic health centers, state or local governments, and other appropriate public or private nonprofit entities for stipends and scholarships so as to increase nursing education opportunities for disadvantaged individuals. 3. Nurse education, practice, quality, and retention (PHSA Sec. 831) – see ACA Sec. 5309(a) above. Note: ACA did not reauthorize funding for the nursing education loan repayment and scholarship programs authorized under PHSA Sec. 846.b CRS-13 FY2011 funding = $40 million, FY2012 funding = $39 million, FY2013 request = $39 million. [CFDA 93.359, 93.503] FY2011 funding = $25 million, FY2012 funding = $25 million, FY2013 request = $25 million. [CFDA 93.264] Sec. 811: FY2011 funding = $64 million, FY2012 funding = $64 million, FY2013 request = $84 million (includes $20 million in PHS evaluation funds).a [CFDA 93.124, 93.247, 93.358, 93.513] Sec. 821: FY2011 funding = $16 million, FY2012 funding = $16 million, FY2013 request = $16 million. [CFDA 93.178] Sec. 831: see ACA Sec. 5309(a) above for funding amounts. Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) ACA Section Statutory Authority (Agency) Summary of Provision Authorization of Appropriations Funding (FY2011-FY2013) Nursing: New Programs 5309(b) New PHSA Sec. 831A (HRSA) Nurse retention program. New authority that largely duplicates the nurse retention grant program authorized under PHSA Sec. 831; see ACA Sec. 5309(a) above. SSAN for each of FY2010 through FY2012. See also ACA Sec. 5312 above. 5311(b) New PHSA Sec. 847 (HRSA) Nursing faculty loan repayment program. Authorizes a loan repayment program for qualified nursing students or graduates who agree to serve as nursing faculty for four to six years. Sets the annual loan limit for FY2010 and FY2011 at $10,000 for individuals with a master’s or equivalent degree in nursing ($20,000 for those with a doctorate or equivalent degree in nursing), and an aggregate loan limit of $40,000 for individuals with a master’s or equivalent degree in nursing ($80,000 for those with a doctorate or equivalent degree in nursing). Thereafter, the annual and aggregate loan limits are subject to a cost-ofattendance adjustment. SSAN for each of FY2010 through FY2014. 5316 New authority Family nurse practitioner demonstration program. Requires the Secretary to award three-year demonstration grants to FQHCs and NMHCs, not to exceed $600,000 a year, for programs to train nurse practitioners as primary care providers (as defined in ACA Sec. 5208). Preference given to bilingual individuals. SSAN for each of FY2011 through FY2014. Geriatrics and Long-Term Care: Existing Program 5305(c) Amends and reauthorizes PHSA Sec. 865; previously Sec. 855 (HRSA) Geriatric nursing education and training. Provides grants for traineeships for individuals preparing for advanced degrees in geriatric nursing or other nursing areas that specialize in elder care. Eligible grantees include nursing schools, health care facilities, programs leading to certification as a certified nurse assistant, and partnerships of such schools, facilities, and programs. SSAN for each of FY2010 through FY2014. FY2011 funding = $5 million, FY2012 funding = $4 million, FY2013 request = $4 million. [CFDA 93.265] Geriatrics and Long-Term Care (LTC): New Programs 5302 CRS-14 New PHSA Sec. 747A (HRSA) Direct care worker training. Requires the Secretary to establish a grant program to provide new training opportunities, such as tuition and fee assistance, for direct care workers employed in LTC settings. Individuals who receive assistance are required to work in the field of geriatrics, disability services, LTC services and supports, or chronic care management for a minimum of two years. Eligible grantees include institutions of higher education that have an established partnership with an LTC entity, as specified. $10 million for the period FY2011 through FY2013. Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) ACA Section 5305(a) Statutory Authority (Agency) Amends PHSA Sec. 753 by adding new subsections (d)(e) (HRSA) Summary of Provision Authorization of Appropriations Funding (FY2011-FY2013) Geriatric workforce development; geriatric career incentive awards. (1) Requires the Secretary to award no more than 24 grants or contracts for $150,000 to entities that operate geriatric education centers to support short-term intensive courses on geriatrics and LTC, and support training for family caregivers and direct care workers. Eligible grantees include accredited schools of allied health, medicine, nursing, dentistry, osteopathic medicine, optometry, podiatric medicine, veterinary medicine, public health, or chiropractic care; accredited graduate programs in clinical psychology, clinical social work, health administration, marriage and family therapy, and counseling; and physician assistant programs. (2) Requires the Secretary to award grants or contracts to advance practice nurses, clinical social workers, pharmacists, and psychologists pursuing an advanced degree in geriatrics or a related field, in return for agreeing to teach or practice in the field of geriatrics, LTC, or chronic care management for a minimum of five years upon completion of the degree. (1) $10.8 million for the period FY2011 through FY2014. (2) $10 million for the period FY2011 through FY2013. Education and training in pain care. Authorizes a grant program to train health professionals in pain care. Eligible grantees include health professions schools, hospices, and other public and private entities. Applicants must agree to include training and education on recognizing the signs and symptoms of pain; applicable laws and policies on controlled substances; interdisciplinary approaches to pain care delivery; barriers to care in underserved populations; and recent developments in pain care. [See also Table 14.] SSAN for each of FY2010 through FY2012, to remain available until expended. Note: Funding for the three existing geriatric education and training programs under PHSA Sec. 753(a)-(c) is as follows: FY2011 funding = $34 million; FY2012 funding = $31 million, FY2013 request = $31 million. [CFDA 93.156, 93.250, 93.969] Pain Care: New Program 4305(c) New PHSA Sec. 759 (HRSA) Public Health: Existing Programs 10501(m)(2) CRS-15 Amends PHSA Sec. 770 (HRSA) Public health and preventive medicine programs. Reauthorizes funding for the public health workforce programs authorized under PHSA Secs. 765-769. They include grants for public health training centers; tuition, fees, and stipends for traineeships in public health and in health administration; and residency programs in preventive medicine and dental public health. Several programs mention preference for underserved communities or underrepresented minorities. Eligible grantees include accredited academic institutions, as well as state, local and tribal public health departments. $43 million for FY2011, and SSAN for each of FY2012 through FY2015. FY2011 funding = $30 million (includes $20 million from the PPHF), FY2012 funding = $33 million (includes $25 million from the PPHF), FY2013 request = $20 million (includes $10 million from the PPHF). [CFDA 93.117, 93.249, 93.516, 93.964] Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) ACA Section Statutory Authority (Agency) Summary of Provision Authorization of Appropriations Funding (FY2011-FY2013) Public Health: New Programs 5204 New PHSA Sec. 776 (HRSA) Public health workforce loan repayment program. Requires the Secretary to establish a student loan repayment program that pays up to $35,000 a year, or one-third of total debt, whichever is less, to increase the supply of public health professionals. Eligible individuals must agree to work for at last three years in a public health agency or related training fellowship. $195 million for FY2010, and SSAN for each of FY2011 through FY2015. 5206(b) New PHSA Sec. 777 (HRSA) Public health and allied health scholarship program. Authorizes grants to accredited institutions for scholarships to help support the training of mid-career professionals in public health and allied health. Available grant funds are to be divided 50:50 between supporting public health and allied health professionals. $60 million for FY2010, and SSAN for each of FY2011 through FY2015. 5313 New PHSA Sec. 399V (CDC) Community health worker (CHW) program. Requires CDC to award grants to promote healthy behaviors and outcomes for populations in medically underserved communities through programs of training and supervision of CHWs. Eligible grantees include states and subdivisions, health departments, free clinics, hospitals, and FQHCs. Priority is to be given to applicants that target areas with a high proportion of uninsured or underinsured individuals, or with high rates of chronic illness or infant mortality. SSAN for each of FY2010 through FY2014. 5314 New PHSA Sec. 778 (CDC) CDC training fellowships. Authorizes the Secretary to expand existing CDC training fellowships in epidemiology, laboratory science, and informatics; the Epidemic Intelligence Service (EIS); and other training programs that meet similar objectives. Participants may be placed in state and local health agencies, and states can receive federal assistance for loan repayment programs for such participants. [CFDA 93.065] $39.5 million for each of FY2010 through FY2013 ($24.5 million for EIS, and $5 million each for epidemiology, laboratory science, and informatics). 5315 New PHSA Title II, Part D – Secs. 271-274 (U.S. Surgeon General) United States Public Health Sciences Track. Authorizes the establishment of a science track at academic sites selected by the Secretary to award degrees that emphasize team-based service, public health, epidemiology, and emergency preparedness and response. Funds may be used for program development and for tuition and stipends for student who meet a service obligation, including in the United States Public Health Service (USPHS) Commissioned Corps. Requires the Secretary to transfer SSAN from the Public Health and Social Services Emergency Fund for FY2010 and each fiscal year thereafter. Note: P.L. 112-10 prohibited any such transfer of funds.c CRS-16 Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) ACA Section 5210 Statutory Authority (Agency) Amends PHSA Sec. 203 (U.S. Surgeon General) Summary of Provision USPHS Commissioned Corps. Establishes a Ready Reserve Corps of officers who are subject to involuntary call to active duty (including for training) by the Surgeon General, in order to bolster the available workforce for both routine and emergency public health missions. Authorization of Appropriations Funding (FY2011-FY2013) $17.5 million for each of FY2010 through FY2014 ($5 million for recruitment and training, $12.5 million for the Ready Reserve Corps). Workforce Diversity, Health Disparities, Cultural Competency: Existing Programs 5307(a) Amends and reauthorizes PHSA Sec. 741 (HRSA) Cultural competency, prevention, public health, disparities, and individuals with disability training. Authorizes grants, contracts, or cooperative agreements under PHSA Title VII (Health Professions Education) for the development and evaluation of research, demonstration projects, and model curricula that provide training in cultural competency, prevention, public health proficiency, reducing health disparities, and aptitude for working with individuals with disabilities. The Secretary is required to coordinate this program with the one authorized under PHSA Sec. 807. SSAN for each of FY2010 through FY2015. 5307(b) Amends and reauthorizes PHSA Sec. 807 (HRSA) Cultural competency, prevention, public health, disparities, and individuals with disability training. Authorizes grants, contracts, or cooperative agreements under PHSA Title VIII (Nursing Workforce Development) for the development and evaluation of research, demonstration projects, and model curricula that provide training in cultural competency, prevention, public health proficiency, reducing health disparities, and aptitude for working with individuals with disabilities. The Secretary is required to coordinate this program with the one authorized under PHSA Sec. 741. SSAN for each of FY2010 through FY2015. 5401 Amends and reauthorizes PHSA Sec. 736 (HRSA) Centers of excellence (COE). Requires the Secretary to fund COEs at health professions schools that recruit, enroll and graduate underrepresented minorities or that recruit underrepresented minorities serving in faculty or administrative positions. $50 million for each of FY2010 through FY2015, and SSAN for each subsequent fiscal year. CRS-17 FY2011 funding = $24 million, FY2012 funding = $23 million, FY2013 request = $23 million. [CFDA 93.157] Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) ACA Section 5402 Statutory Authority (Agency) Amends PHSA Sec. 740 (HRSA) Summary of Provision Authorization of appropriations. Reauthorizes funding for the following PHSA Title VII workforce diversity programs: 1. Scholarships for disadvantaged students (PHSA Sec. 737) – grants to health professions schools for awarding scholarships to students from disadvantaged backgrounds with financial need. 2. Faculty loan repayment program (PHSA Sec. 738) – loan repayment program for health profession graduates from disadvantaged backgrounds who serve as faculty at an eligible health professions college for at least two years. 3. Health careers opportunity program (PHSA Sec. 739) – grants to health professions schools and other educational institutions to improve recruitment and academic preparation of students from disadvantaged backgrounds. 5403(a) Amends and reauthorizes PHSA Sec. 751 (HRSA) Area Health Education Centers (AHECs). Requires the Secretary to award grants (with a matching requirement) to medical and nursing schools of at least $250,000 to (1) plan, develop, and operate AHEC programs; and (2) to maintain and improve the effectiveness of existing AHEC programs. AHECs recruit, train, and prepare individuals from minority populations or from disadvantaged or rural backgrounds to work in medically underserved areas. Authorization of Appropriations Funding (FY2011-FY2013) For Sec. 737, $51 million for FY2010, and SSAN for each of FY2011 through FY2014. For Sec. 738, $5 million for each of FY2010 through FY2014. For Sec. 739, $60 million for FY2010, and SSAN for each of FY2011 through FY2014. Sec. 737: FY2011 funding = $49 million, FY2012 funding = $47 million, FY2013 request = $47. [CFDA 93.925] Sec. 738: FY2011 funding = $1 million, FY2012 funding = $1 million, FY2013 request = $1 million. [CFDA 93.923] Sec. 739: FY2011 funding = $22 million, FY2012 funding = $15 million, FY2013 request = $0. [CFDA 93.822] $125 million for each of FY2010 through FY2014; funds may be carried over for up to three fiscal years. FY2011 funding = $33 million, FY2012 funding = $27 million, FY2013 request = $0. [CFDA 93.107, 93.824] Workforce Diversity, Health Disparities, Cultural Competency: New Program 5403(b) CRS-18 New PHSA Sec. 752 (HRSA) Continuing educational support for health professionals serving in underserved communities. Requires the Secretary to award grants to enhance education through distance learning, continuing education, collaborative conferences, and telehealth, with a focus on primary care. Eligible grantees include health professions schools, academic health centers, state or local governments, or other public or nonprofit entities participating in training activities. [CFDA 93.189] $5 million for each of FY2010 through FY2014, and SSAN for each subsequent fiscal year. Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) ACA Section Statutory Authority (Agency) Summary of Provision Authorization of Appropriations Funding (FY2011-FY2013) Mental and Behavioral Health: New Program 5306 Redesignates PHSA Sec. 756 as Sec. 757, and adds a new Sec. 756 (HRSA) Mental and behavioral health education and training grants. Authorizes grants for the recruitment and education of students in social work, interdisciplinary psychology training, and internships or other field placement programs related to child and adolescent mental health. Priority for social work grants given to schools of social work meeting certain criteria such as recruiting from and placing graduates into areas with a high-need and high-demand population. Priority for psychology grants given to institutions that focus on the needs of specified vulnerable groups. Priority for grants to train professional and paraprofessional child and adolescent mental health workers given to applicants that can, among other things, assess workforce needs and that have programs designed to increase the number of child and adolescent mental health workers serving high-priority populations. $35 million for the period of FY2010 through FY2013 ($8 million for training in social work, $12 million for training in graduate psychology, $10 million for training in professional child and adolescent mental health, and $5 million for training in paraprofessional child and adolescent mental health). FY2012 funding = $10 million from the PPHF, FY2013 request = $5 million in PHS evaluation funds.a [CFDA 93.732] Note: The existing graduate psychology education program received $3 million in FY2011 and in FY2012; the FY2013 request is for the same amount. Policy and Planning: Existing Program 5103 Amends and reauthorizes PHSA Sec. 761 (HRSA) Health care workforce program assessment. Requires the Secretary to establish a National Center for Health Care Workforce Analysis, award grants to support state and regional centers for health workforce analysis, and increase funding for longitudinal evaluations of specified individuals who have received education, training, or financial assistance from programs under PHSA Title VII. For the National Center, $7.5 million for each of FY2010 through FY2014; for state and regional centers, $4.5 million for each of FY2010 through FY2014; and for longitudinal evaluations, SSAN for FY2010 through FY2014. FY2011 funding = $3 million, FY2012 funding = $3 million, FY2013 request = $10 million. Note: Includes funding for Sec. 792 (health professions data) and Sec. 806 (nursing grant program data). FY2013 request is all PHS evaluation funds.a [CFDA 93.300] Policy and Planning: New Programs 5101 CRS-19 New authority National Health Care Workforce Commission. Establishes a 15member commission focused on evaluating and meeting the need for health care workers in the United States. The commission is required to conduct studies, produce annual reports beginning in 2011, and make recommendations on high-priority topics related to the health care workforce. SSAN (no years specified). Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) Statutory Authority (Agency) ACA Section 5102 New authority (HRSA) Summary of Provision State health care workforce development grants. Establishes a matching grants program for state partnerships to plan and implement activities leading to coherent and comprehensive health care workforce development strategies at the state and local levels. Planning grants of up to $150,000 are for up to one year and require a 15% match. Implementation grants are for up to two years (with up to one additional year of funding) and require a 25% match. Authorization of Appropriations Funding (FY2011-FY2013) For planning grants, $8 million for FY2010, and SSAN for each subsequent fiscal year. For implementation grants, $150 million for FY2010, and SSAN for each subsequent fiscal year. Note: This program received $6 million in FY2010 funds from the PPHF. [CFDA 93.509] Sources: Table 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). FY2011, FY2012 and requested FY2013 funding amounts are taken from HHS FY2013 budget justification documents for Congress, available at http://www.hrsa.gov/about/ budget/index.html. a. PHSA Sec. 241 authorizes the Secretary to use a portion of the funds appropriated for PHSA programs to evaluate their implementation and effectiveness. Under this authority a number of HHS agencies and offices are subject to a budget tap, called the PHS Program Evaluation Set-Aside. The tapped evaluation funds are redistributed and used for evaluation and other specific programs within HHS. b. The nursing education loan repayment program repays 60% of a registered nurse’s educational loans in return for a two-year commitment to work in a health care facility with a critical shortage of nurses. Participants may have an additional 25% of their loan repaid in exchange for one more year of service. The nurse scholarship program offer scholarships to individuals attending nursing school in exchange for at least two years working in a health care facility with a critical shortage of nurses. Together the two programs, authorized under PHSA Sec. 846, received $94 million in FY2010 and $93 million in FY2011. The authorization of appropriations for Sec. 846 expired at the end of FY2007 and was not reauthorized by ACA. c. The Department of Defense and Full-Year Continuing Appropriations Act, 2011 (P.L. 112-10, Div. B, Sec. 1828) prohibited the transfer of funds from the Public Health and Social Services Emergency Fund (PHSSEF) to support the U.S. Public Health Sciences Track. The PHSSEF is an HHS account administered by the Secretary. Congress has historically used the PHSSEF to provide one-time funding for non-routine activities. Each fiscal year, Congress appropriates amounts to the PHSSEF for specified purposes. ACA did not authorize or appropriate funds to the PHSSEF. CRS-20 Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) Table 3. ACA Discretionary Spending: Prevention and Wellness ACA Section Statutory Authority (Agency) Summary of Provision Authorization of Appropriations Funding (FY2011-FY2013) Community-Based Prevention: Existing Programs 3509/3511 4003 4102(b) 4204 CRS-21 New PHSA Secs. 229 (OS), 310A (CDC), 925 (AHRQ); new SSA Sec. 713 (HRSA); and new FFDCA Sec. 1011 (FDA). Reauthorizes PHSA Secs. 486(a) (NIH) and 501(f) (SAMHSA). Offices on Women’s Health. Establishes or reauthorizes offices of women’s health in OS, CDC, AHRQ, HRSA, FDA, NIH, and SAMHSA. Grants, agreements, or contracts may be awarded for activities of the OS office to establish an information center and coordinating committee. Activities of other offices include recommendations regarding grant-making through other agency accounts, not direct grantmaking. For most offices, SSAN for each of FY2010 through FY2014. For NIH and SAMHSA offices, SSAN (no years specified). Amends PHSA Sec. 915(a) (AHRQ). New PHSA Sec. 399U (CDC). Clinical and community preventive services task forces. Reauthorizes and expands the authority for the U.S. Preventive Services Task Force (USPSTF) to review and recommend effective clinical preventive services. Provides explicit statutory authority for the existing Task Force on Community Preventive Services (TFCPS) to review and recommend effective community-based interventions. SSAN for each fiscal year to carry out the activities of the USPSTF and the TFCPS. Amends PHSA Sec. 317M(c) (CDC, HRSA) School-based dental sealant program. Amends the existing schoolbased dental sealant grant program, which was discretionary, by requiring the Secretary to award grants to the 50 states and to Indian tribes for school-based dental sealant programs. Authority expired at end of FY2005; ACA does not authorize new funding. Amends PHSA Sec. 317 and adds a new subsection (m) (CDC) Immunization programs. Provides explicit authority for states to purchase vaccines at prices negotiated by Secretary. Permanently reauthorizes state immunization grants. Requires new immunization demonstration grants. OS Office on Women’s Health: FY2011 funding = $34 million, FY2012 funding = $34 million, FY2013 request = $29 million. NIH Office of Research on Women’s Health: FY2011 funding = $42 million, FY2012 funding = $42 million, FY2013 request = S42 million. USPSTF: Funding for each of FY2011, FY2012, and the FY2013 request = $11 million (includes $7 million from the PPHF). Funding for all CDC’s existing oral health programs under Sec. 317M: FY2011 = $15 million; FY2012 = $15 million, FY2013 request = $15 million. SSAN for each of FY2010 through FY2014 for demonstration grants; SSAN (no years specified) for other authorities. Funding for the Sec. 317 vaccination program: FY2011 = $589 million (includes $100 million from the PPHF), FY2012 = $620 million (includes $190 million from the PPHF), FY2013 request = $562 million (includes $72 million from the PPHF). [CFDA 93.185, 93.268, 93.533, 93.539] Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) ACA Section 10334 10412 Statutory Authority (Agency) Amends PHSA Sec. 1707 (OS) and PHSA Title IV (NIH) Reauthorizes PHSA Sec. 312 (HRSA) Summary of Provision Authorization of Appropriations Funding (FY2011-FY2013) Offices of Minority Health. Elevates the existing OS Office of Minority Health and NIH National Center on Minority Health and Health Disparities (NCMHD); instructs the OS office to award grants and undertake other activities to improve minority health status; and gives the new NIH National Institute on Minority Health and Health Disparities (NIMHD) responsibility for minority health disparities research and other health disparities research at NIH. SSAN for each of FY2011 through FY2016 for OS office. Rural access to emergency devices. Reauthorizes a program of grants to community partnerships for the purchase and distribution of automatic external defibrillators (AEDs) in rural communities, and to support AED training for first responders. $25 million for each of FY2003 through FY2014. NIMHD: FY2011 funding = $276 million, FY2012 funding = $276 million, FY2013 request = $279 million. OS Office of Minority Health: FY2011 funding = $56 million, FY2012 funding = $56 million, FY2013 request = $41 million. FY2011 funding = $236,000, FY2012 funding = $1 million, FY2013 request = $0. [CFDA 93.259] Community-Based Prevention: New Programs 4004 New authority Education and outreach regarding prevention. Requires the Secretary to carry out various specified communications activities regarding health promotion and disease prevention, for common and serious chronic health problems. They include establishing, within one year of enactment, a national media campaign on health promotion and disease prevention. SSAN for each fiscal year; no more than $500 million total. 4102(a) New PHSA Secs. 399LL, 399LL-1, and 399LL-2 (CDC) Oral health activities. Requires CDC, subject to appropriations, to fund a five-year national oral health education campaign, and award grants to community-based providers of dental services for dental caries disease management programs, among other things. SSAN (no years specified). 4102(c) Amends PHSA Sec. 317M by adding a new subsection (d) (CDC) Oral health infrastructure. Requires the Secretary to enter into cooperative agreements with states and tribal entities to establish oral health leadership and programs to improve oral health. SSAN for FY2010 through FY2014. 4102(d) New authority (CDC, AHRQ) Oral health surveillance. Requires the Secretary to expand the following surveillance systems to include more information on oral health: Pregnancy Risk Assessment Monitoring System (PRAMS); National Health and Nutrition Examination Survey (NHANES); National Oral Health Surveillance System (NOHSS); and Medical Expenditure Panel Survey (MEPS). SSAN (no years specified) for PRAMS; SSAN for each of FY2010 through FY2014 for NOHSS; no explicit authorization of appropriations for NHANES/MEPS expansion. CRS-22 Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) ACA Section 4201 Statutory Authority (Agency) Summary of Provision Authorization of Appropriations Funding (FY2011-FY2013) New authority (CDC) Community transformation grants. Requires CDC to fund competitive grants for the implementation, evaluation, and dissemination of evidence-based community preventive health activities. SSAN for each of FY2010 through FY2014. 4202(a) New authority (CDC) Community wellness pilot program. Requires CDC to award grants state and local health departments, and to Indian tribes, for fiveyear pilot programs to provide community prevention interventions, screenings, and clinical referrals for individuals between 55 and 64 years of age. SSAN for each of FY2010 through FY2014. 4206 Amends PHSA Sec. 330 by adding a new subsection (s) Individualized wellness plan demonstration program. Requires the Secretary to establish a pilot program in not more than 10 community health centers to test the impact of providing at-risk individuals who use the centers with individualized wellness plans. SSAN (no years specified). 4304 New PHSA Sec. 2821 (CDC) Epidemiology and laboratory capacity grants. Codifies existing grant programs to strengthen national epidemiology, laboratory, and information management capacity for the response to infectious diseases and other conditions of public health importance. $190 million for each of FY2010 through FY2013 (at least $95 million for epidemiology, $60 million for information management, and $32 million for laboratories). FY2011 funding = $145 million, FY2012 funding = $226 million, FY2013 request = $146 million; all funds are from the PPHF. [CFDA 93.531] Funding for Epidemiology and Laboratory Capacity (ELC) and Emerging Infections Program (EIP): FY2011 = $49 million (includes $40 million from the PPHF), FY2012 = $53 million (includes $40 million from the PPHF), FY2013 request = $53 million (includes $40 million from the PPHF. 10407 New authority (CDC) Diabetes activities. Requires CDC to conduct several diabetes prevention activities including state assessments, vital statistics, physician education, and funding of an Institute of Medicine (IOM) report. SSAN (no years specified). 10411 New PHSA Secs. 399V-2 (CDC) and 425 (NIH) Congenital heart disease programs. Authorizes CDC to establish a National Congenital Heart Disease Surveillance System (NCHDSS), or to award one grant to establish such a system. Authorizes NIH to expand and coordinate research on congenital heart disease. SSAN for each of FY2011 through FY2015 for both the surveillance system and the expanded research program. New PHSA Sec. 399NN (OS, CDC) Young women’s breast health awareness. Among other things, requires CDC to conduct an education campaign and award grants for a media campaign regarding breast health in young women, and to conduct prevention research; requires the Secretary to award grants to provide education and assistance to young women diagnosed with breast disease. $9 million for each of FY2010 through FY2014. 10413 CRS-23 FY2012 funding = $2million, FY2013 request amount not specified. FY2011 funding = $5 million, FY2012 funding = $5 million, FY2013 request = $5 million. Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) Statutory Authority (Agency) ACA Section 10501(g) New PHSA Sec. 399V-3 (CDC) Summary of Provision National diabetes prevention program. Among other things, requires the Secretary to award grants for community-based diabetes prevention program model sites. Authorization of Appropriations Funding (FY2011-FY2013) SSAN for each of FY2010 through FY2014. FY2011 funding = $10 million, FY2012 funding = $10 million (all PPHF), FY2013 request = $10 million (all PPHF). Workplace Wellness: New Program 10408 New authority (CDC) Small business wellness program. Requires the Secretary to award grants to employers to provide their employees with access to comprehensive workplace wellness programs. Eligible employers are those with fewer than 100 employees, who work at least 25 hours per week. $200 million for the period of FY2011 through FY2015, to remain available until expended. FY2011 funding = $10 million, FY2012 funding = $10 million, FY2013 request = $4 million; all funds are from the PPHF. Sources: Table 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). FY2011, FY2012 and requested FY2013 funding amounts are taken from HHS FY2013 budget justification documents for Congress, available at http://www.hrsa.gov/about/ budget/index.html. Table 4. ACA Discretionary Spending: Maternal and Child Health Statutory Authority (Agency) New SSA Sec. 512 (HRSA) ACA Section 2952(b) Summary of Provision Services to individuals with a postpartum condition. Authorizes grants to establish, operate and coordinate effective and cost-efficient systems for the delivery of essential services to individuals with, or at risk of, postpartum depression and their families. Eligible grantees include public or nonprofit private entities, state or local government public-private partnerships, recipients of Healthy Start grants, public or nonprofit private hospitals, community-based organizations, hospices, ambulatory care facilities, community health centers, and primary care centers. Authorization of Appropriations Funding (FY2011-FY2013) $3 million for FY2010, and SSAN for each of FY2011 and FY2012. Source: Table 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). CRS-24 Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) Table 5. ACA Discretionary Spending: Health Care Quality ACA Section Statutory Authority (Agency) Summary of Provision Authorization of Appropriations Funding (FY2011-FY2013) Quality Measure Development, Analysis, and Public Reporting: New Programs 3013(a)&(c) New PHSA 931 (AHRQ) Quality measure development. Requires the Secretary, in consultation with AHRQ and CMS, to (1) identify gaps where no quality measures exist or where existing measures need improvement, updating or expansion consistent with the National Strategy for Quality Improvement; and (2) fund or enter into agreements with eligible entities that have demonstrated expertise in measure development to develop, improve, update or expand quality measures in areas identified as gap areas. $75 million for each of FY2010 through FY2014, to remain available until expended. At least 50% of the amounts appropriated must be used pursuant to SSA Sec. 1890A(e), as added by ACA Sec. 3013(b). See below. 3013(b) Amends new SSA Sec. 1890A, as added by ACA Sec. 3014(b), by adding a new subsection (e) (CMS) Quality and efficiency measures development. Requires CMS, in consultation with AHRQ, through contracts, to develop quality and efficiency measures as determined appropriate for use under the SSA. See ACA Sec. 3013(a)&(c) above. 3015 New PHSA Sec. 399II Collection and analysis of data for quality and resource use measures. Requires the Secretary to establish and implement an overall strategic framework to carry out the public reporting of performance information. Requires the Secretary to collect and aggregate consistent data on quality and resource use measures, and authorizes the Secretary to award grants or contracts for this purpose. Authorizes the Secretary to award grants or contracts to multistakeholder entities to support new, or improve existing, efforts to collect and aggregate quality and resource use measures. SSAN for each of FY2010 through FY2014. 3015 New PHSA Sec. 399JJ Public reporting of performance information. Requires the Secretary to make available to the public, through standardized websites, performance information summarizing data on quality measures. The information must include clinical conditions to the extent such data is available and, where appropriate, be provider-specific and sufficiently disaggregated and specific to meet the needs of patients with different clinical conditions. SSAN for each of FY2010 through FY2014. CRS-25 Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) ACA Section Statutory Authority (Agency) Summary of Provision Authorization of Appropriations Funding (FY2011-FY2013) Quality Improvement Research, Training, and Implementation: New Programs 3501 New PHSA Sec. 933 (AHRQ) Health care delivery system research. Requires AHRQ to (1) identify, develop, evaluate, and disseminate innovative strategies for quality improvement practices in the delivery of health care services that represent best practice; (2) support research on health care delivery improvement and facilitate adoption of best practices; and (3) make the research findings available to the public; among other specified functions. $20 million for FY2010 through FY2014. 3501/3511 New PHSA Sec. 934 (AHRQ) Quality improvement technical assistance and implementation. Requires AHRQ to award grants (with a matching requirement) to eligible entities for providing technical support to health care providers in order to help them understand, adapt, and implement the models and practices identified by the research conducted by the agency. Grantees must have demonstrated expertise in providing information and technical support and assistance to health care providers regarding quality improvement. SSAN (no years specified). 3508/3511 New authority Quality and patient safety training. Authorizes the Secretary to award demonstration grants (with a matching requirement) to eligible health professions schools or consortia to develop and implement academic curricula that integrate quality improvement and patient safety into clinical education of health professionals. SSAN (no years specified). Health Care Coordination: Existing Program 3510 CRS-26 Amends and reauthorizes PHSA Sec. 340A (HRSA) Patient navigator program. Prohibits the Secretary from awarding a grant to an entity under this section unless the entity provides assurances that patient navigators recruited, assigned, trained, or employed using these grant funds meet certain minimum core proficiencies. Eligible grantees include public or nonprofit private health centers (including an FQHCs), IHS facilities, hospitals, cancer centers, rural health clinics, academic health centers, and nonprofit entities that partner or coordinate referrals with such a facility to provide patient navigator services. $3.5 million for FY2010, and SSAN for each of FY2011 through FY2015. FY2011 funding = $5 million, FY2012 funding = $0, FY2013 request = $0. [CFDA 93.191] Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) ACA Section Statutory Authority (Agency) Summary of Provision Authorization of Appropriations Funding (FY2011-FY2013) Health Care Coordination: New Programs 3502/3511 New authority Community health team grants to support medical homes. Requires the Secretary to award grants to or enter into contracts with states, state-designated entities, and tribal organizations to support community-based interdisciplinary, interprofessional health teams in assisting primary care practices. Funding must be used to establish the health teams and to provide capitated payments to the providers. SSAN (no years specified). 3503/3511 New PHSA Sec. 935 (AHRQ) Medication therapy management (MTM) grants. Requires the Secretary, not later than May 1, 2010, to provide grants to support MTM services provided by licensed pharmacists that are targeted at patients who take four or more prescribed medications, take high-risk medications, have two or more chronic diseases, or have undergone a transition of care or other factors that are likely to create a high risk for medication-related problems. SSAN (no years specified). 3506 New PHSA Sec. 936 (AHRQ) Program to facilitate shared decision making. Requires the Secretary, through a contract, to develop and identify standards for patient decision aids, to review patient decision aids, and develop a certification process for determining whether patient decision aids meet those standards. The contract is to be awarded to the entity that holds the contract under SSA Sec. 1890 (currently the National Quality Forum). Further requires the Secretary to (1) award grants or contracts to develop, update, and produce patient decision aids, to test such materials to ensure they are balanced and evidence-based, and to educate providers on their use; and (2) to award grants for establishing Shared Decision Making Resource Centers to develop and disseminate best practices to speed adoption and effective use of patient decision aids and shared decision making. Also requires the Secretary to award grants to providers for the development and implementation of shared decision-making techniques. SSAN for FY2010 and each subsequent fiscal year. CRS-27 Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) Statutory Authority (Agency) ACA Section Summary of Provision Authorization of Appropriations Funding (FY2011-FY2013) 5405 New PHSA Sec. 399V-1 (AHRQ) Primary care extension program. Requires the Secretary to establish a Primary Care Extension Program to award state planning and implementation grants for Primary Care Extension Program State Hubs, consisting of the state health department and other specified entities. State hubs must contract with and provide grant funds to county and local entities to serve as Primary Care Extension Agencies that assist primary care providers in implementing patient-centered medical homes and develop and support primary care learning communities, among other functions. $120 million for each of FY2011 and FY2012, and SSAN for each of FY2013 and FY2014. 5604 New PHSA Sec. 520K (SAMHSA) Co-locating primary and specialty care in community-based mental health settings. Requires the Secretary to fund demonstration projects for providing coordinated and integrated services to individuals with mental illness and co-occurring chronic diseases through the co-location of primary and specialty care services in community-based mental and behavioral health settings. $50 million for FY2010, and SSAN for each of FY2011 through FY2014. 10333 New PHSA Sec. 340H Community-based collaborative care network program. Authorizes the Secretary to award grants to support community-based collaborative care networks (CCN). An eligible CCN is a consortium of health care providers with a joint governance structure that provides comprehensive coordinated and integrated health care services (as defined by the Secretary) for low-income populations. CCNs must include a safety net hospital and all FQHCs in the community, as specified. SSAN for each of FY2011 through FY2015. 10410 New PHSA Sec. 520B (SAMHSA) Centers of excellence for depression. Requires SAMHSA to award five-year grants (with a matching requirement) on a competitive basis to eligible institutions of higher education or research institutions to establish national centers of excellence for depression. One grantee is to be designated as the coordinating center and required to establish and maintain a national database. Centers of excellence may receive a grant of up to $5 million; the coordinating center may receive a grant of up to $10 million. $100 million for each of FY2011 through FY2015, and $150 million for each of FY2016 through FY2020. Note: SAMHSA’s Primary & Behavioral Health Care Integration (PBHCI) program, authorized under PHSA Sec. 520A, predates ACA and has received the following amounts: FY2011 funding = $63 million (includes $35 million from the PPHF), FY2012 = $68 (includes $35 million from the PPHF), FY2013 request = $28 million (all PPHF). Sources: Table 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). FY2011, FY2012 and requested FY2013 funding amounts are taken from HHS FY2013 budget justification documents for Congress, available at http://www.hrsa.gov/about/ budget/index.html. CRS-28 Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) Table 6. ACA Discretionary Spending: Nursing Homes Statutory Authority (Agency) ACA Section Summary of Provision Authorization of Appropriations Funding (FY2011-FY2013) 6112 New authority National independent monitor demonstration program. Requires the Secretary, within one year of enactment, to implement a two-year demonstration to develop, test, and implement an independent monitoring program to oversee interstate and large intrastate chains of skilled nursing facilities (SNFs) and nursing facilities (NFs). SSAN (no years specified); a monitored chain must contribute a portion of costs of the demonstration, as determined by the Secretary. 6114 New authority Culture change and information technology demonstration programs. Requires the Secretary, within one year of enactment, to award one or more competitive grants to support each of the following two three-year demonstration projects for SNFs and NFs: (1) develop best practices for culture change (i.e., patient-centric models of care); and (2) develop best practices for the use of health information technology. SSAN (no years specified). Source: Table 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). CRS-29 Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) Table 7. ACA Discretionary Spending: Health Disparities Data Collection Statutory Authority (Agency) ACA Section Summary of Provision Authorization of Appropriations Funding (FY2011-FY2013) 4302(a) New PHSA Title XXXI; new Sec. 3101 Health disparities data collection and analysis. Not later than two years after enactment, requires federally conducted and supported health programs and surveys, to the extent practicable, to collect and report data on race, ethnicity, sex, primary language, and disability status, as well as other demographic data on health disparities as deemed appropriate by the Secretary. Requires the Secretary to adopt standards for the measurement and collection of such data. Requires the Secretary to analyze the data collected on health disparities; provide for the public reporting and dissemination of the data and analyses; and safeguard the privacy of the information. [Note: On October 31, 2011, HHS published final standards for collecting and reporting health disparities data. See http://minorityhealth.hhs.gov/templates/ browse.aspx?lvl=2&lvlid=208.] SSAN for each of FY2010 through FY2014; however, data may not be collected unless funds are directly appropriated for such purpose. 5605 New authority Key national indicators. Establishes a Commission on Key National Indicators composed of eight members appointed by Congress. [Note: The Commission members were appointed in Dec. 2010. See http://www.stateoftheusa.org/content/commission-on-key-nationalind.php.] Requires the commission to contract with the National Academy of Sciences to review available public and private sector research on key national indicator set selection and determine how best to establish a key national indicator system, among other things. Mandates a Government Accountability Office (GAO) study of previous efforts by public, private, or foreign entities to develop best practices for a key national indicator system. [Note: GAO released its study in March 2011. See http://www.gao.gov/new.items/d11396.pdf.] $10 million for FY2010, and $7.5 million for each of FY2011 through FY2018, with amounts appropriated to remain available until expended. Source: Table 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). CRS-30 Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) Table 8. ACA Discretionary Spending: Emergency Care and Trauma Services Statutory Authority (Agency) ACA Section Summary of Provision Authorization of Appropriations Funding (FY2011-FY2013) Emergency Care and Trauma Services: Existing Programs 3505(a) Amends and reauthorizes PHSA Secs. 12411245 (HRSA) Trauma care centers. Requires the Secretary to establish separate grant programs for IHS and tribal trauma care centers to (1) help defray substantial uncompensated care costs, (2) further the core missions of trauma care centers, and (3) provide emergency relief to ensure the continued availability of trauma services. $100 million for FY2009, and SSAN for each of FY2010 through FY2015. 5603 Amends and reauthorizes PHSA Sec. 1910 (HRSA) Children’s emergency medical services demonstration grants. Expands emergency services for children who need treatment for trauma or critical care by lengthening the period for demonstration grants to four years (with an optional fifth year). $25 million for FY2010, $26.3 million for FY2011, $27.6 million for FY2012, $28.9 million for FY2013, and $30.4 million for FY2014. FY2011 funding = $21 million, FY2012 funding = $21 million, FY2013 request = $21 million. [CFDA 93.127] Emergency Care and Trauma Services: New Programs 3504(a) New PHSA Sec. 1204 (OS) Regional systems for emergency care. Requires the Assistant Secretary for Preparedness and Response to award at least four multiyear contracts or grants (with matching requirement) to states and Indian tribes for pilot projects to improve regional coordination of emergency services. Priority given to entities that serve a medically underserved population. $24 million for each of FY2010 through FY2014. 3504(b) New PHSA Sec. 498D (NIH, AHRQ, HRSA, CDC) Emergency medicine research. Requires the Secretary to expand and accelerate basic, translational, and service delivery research on emergency medical care systems and emergency medicine, including pediatric emergency medical care. Also requires the Secretary to support research on the economic impact of coordinated emergency care systems. SSAN for each of FY2010 through FY2014. 3505(b) New PHSA Secs. 1281-1282 Trauma service availability grants. Requires the Secretary to award grants to states for the purpose of supporting trauma-related physician specialties and broadening access to and availability of trauma care services. States must use at least 40% of the funds for grants to safety net trauma centers. $100 million for each of FY2010 through FY2015. Note: This provision reauthorized funding for several existing trauma care grant programs in PHSA Title XII Parts A and B (i.e., Secs. 1202, 1203, and 1211-1222), as well as for the new program (i.e., Sec. 1204). Sources: Table 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). FY2011, FY2012 and requested FY2013 funding amounts are taken from HRSA’s FY2013 budget justification document for Congress, available at http://www.hrsa.gov/ about/budget/index.html. CRS-31 Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) Table 9. ACA Discretionary Spending: Elder Justice ACA Section 6703(a) Statutory Authority (Agency) New SSA Sec. 2021 (OS) 6703(a) New SSA Sec. 2022 6703(a) New SSA Sec. 2024 6703(a) New SSA Sec. 2031 6703(a) New SSA Sec. 2041(a) 6703(a) New SSA Sec. 2041(b) 6703(a) New SSA Sec. 2041(c) 6703(a) New SSA Sec. 2042(a) CRS-32 Summary of Provision Elder Justice Coordinating Council. Establishes an Elder Justice Coordinating Council to include the Secretary as chair and the U.S. Attorney General, as well as the head of each federal department or agency, identified by the chair, as having administrative responsibility or administering programs related to elder abuse, neglect, and exploitation. Advisory Board on Elder Abuse, Neglect, and Exploitation. Establishes an advisory board to create a short- and long-term multidisciplinary plan for development of the field of elder justice and to make recommendations to the Elder Justice Coordinating Council. Authorization of appropriations. Authorizes funding for new SSA Secs. 2021 (Coordinating Council), 2022 (Advisory Board), and 2023 (human subject protection guidelines for researchers). Forensic centers and expertise. Requires the Secretary to award grants to eligible entities to establish and operate stationary and mobile forensic centers and to develop forensic expertise pertaining to elder abuse, neglect, and exploitation. Incentives for LTC staffing. Requires the Secretary to award grants to LTC facilities for them to offer continuing training and varying levels of certification to employees providing direct care to residents, and to improve management practices so as to promote retention of direct care workers. Certified EHR technology grant program. Authorizes grants to LTC facilities for specified activities that would assist such entities in offsetting costs related to purchasing, leasing, developing, and implementing certified electronic health record technology. Standards for transactions involving clinical data by LTC facilities. Requires the Secretary to adopt electronic standards for the exchange of clinical data by LTC facilities and, within 10 years, to have in place procedures to accept the optional electronic submission of clinical data by LTC facilities pursuant to such standards. Adult protective service functions. Requires the Secretary to undertake various activities with respect to adult protective services, including providing funding, collecting and disseminating data on elder abuse, disseminating information on best practices and training, conducting research, and providing technical assistance to states and other entities. Authorization of Appropriations Funding (FY2011-FY2013) SSAN (no years specified). See also new SSA Sec. 2024 below. SSAN (no years specified). See also new SSA Sec. 2024 below. $6.5 million for FY2011, and $7.0 million for each of FY2012 through FY2014. $4 million for FY2011, $6 million for FY2012, and $8 million for each of FY2013 and FY2014. For new SSA Sec. 2041: $20 million for FY2011, $17.5 million for FY2012, and $15 million for each of FY2013 and FY2014. See above authorization of appropriations for SSA Sec. 2041. See above authorization of appropriations for SSA Sec. 2041. $3 million for FY2011, and $4 million for each of FY2012 through FY2014. Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) Statutory Authority (Agency) New SSA Sec. 2042(b) ACA Section 6703(a) 6703(a) New SSA Sec. 2042(c) 6703(a) New SSA Sec. 2043(a) 6703(a) New SSA Sec. 2043(b) 6703(b) New authority 6703(b) New authority 6703(c) New authority Summary of Provision Grants to enhance provision of adult protective services. Requires the Secretary to award formula grants to states to enhance adult protective services programs provided by states and local governments. Adult protective services demonstration grants. Requires the Secretary to fund state demonstration programs for adult protective services that test methods to prevent and detect elder abuse. Long-term care ombudsman program grants. Requires the Secretary to award grants to improve the capacity of state LTC ombudsman programs to address abuse and neglect complaints, conduct pilot programs, and provide support for such programs. Ombudsman training programs. Requires the Secretary to establish programs to provide and improve ombudsman training with respect to elder abuse, neglect, and exploitation for national organizations and state LTC ombudsman programs. National Training Institute for Surveyors. Requires that the Secretary enter into a contract with an entity to establish and operate a National Training Institute for Federal and State Surveyors to provide and improve training of surveyors investigating allegations of abuse in programs and LTC facilities that receive payments under Medicare or Medicaid. Grants to state survey agencies. Requires the Secretary to award grants to state survey agencies that perform surveys of Medicare or Medicaid participating nursing facilities to design and implement complaint investigation systems. National nurse aide registry study and report. Requires the Secretary, in consultation with appropriate government agencies and private sector organizations, to conduct a study on establishing a national nurse aide registry and report on its findings. Authorization of Appropriations Funding (FY2011-FY2013) $100 million for each of FY2011 through FY2014. $25 million for each of FY2011 through FY2014. $5 million for FY2011, $7.5 million for FY2012, and $10 million for each of FY2013 and FY2014. $10 million for each of FY2011 through FY2014. $12 million for the period of FY2011 through FY2014. $5 million for each of FY2011 through FY2014. SSAN (no years specified) to carry out these activities, with funding not to exceed $500,000. Source: Table 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). CRS-33 Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) Table 10. ACA Discretionary Spending: Biomedical Research Statutory Authority (Agency) ACA Section 10409 Amends PHSA Secs. 402(b) and 499(c); new PHSA Sec. 402C (NIH) Authorization of Appropriations Funding (FY2011-FY2013) Summary of Provision Cures Acceleration Network (CAN). Establishes a CAN program within the Office of the NIH Director to award grants, contracts, or cooperative agreements to support the development of treatments for diseases or conditions that are rare, and for which market incentives are inadequate. Eligible grantees include public or private entity, which may include a private or public research institution, an institution of higher education, a medical center, a biotechnology company, a pharmaceutical company, a disease advocacy organization, a patient advocacy organization, or an academic research institution. $500 million for FY2010, and SSAN for subsequent fiscal years. Other funds appropriated under the PHSA may not be allocated to CAN. FY2012 funding = $10 million, FY2013 request = $50 million. Source: Table 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). Table 11. ACA Discretionary Spending: Biologics Statutory Authority (Agency) ACA Section 7002 Amends PHSA Sec. 351 (FDA) Summary of Provision FDA approval of follow-on biologics. Creates an abbreviated regulatory pathway for approving biological products that are demonstrated to be biosimilar to, or interchangeable with, an FDAlicensed biological product. Provides for the collection of user fees, subject to congressional authorization, to cover regulatory costs beginning in FY2013. [Note: On February 9, 2012, FDA released three guidance documents to assist industry in developing biosimilar products and submitting them to the agency for approval. See http://www.fda.gov/ Drugs/DevelopmentApprovalProcess/ HowDrugsareDevelopedandApproved/ApprovalApplications/ TherapeuticBiologicApplications/Biosimilars/default.htm.] Authorization of Appropriations Funding (FY2011-FY2013) SSAN for each of FY2010 through FY2012. Source: Table 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). CRS-34 Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) Table 12. ACA Discretionary Spending: 340B Drug Pricing Statutory Authority (Agency) ACA Section 7102 Amends PHSA Sec. 340B(d) (HRSA) Summary of Provision Improvements to 340B program integrity. Requires the Secretary to develop systems to improve compliance and program integrity to (1) increase transparency and strengthen monitoring, oversight, and investigation of the prices that manufacturers charge covered entities; and (2) ensure covered entities do not divert drugs or obtain multiple discounts. Further requires the Secretary to establish a new administrative dispute resolution process to mediate and resolve covered entity overpayment claims and manufacturer claims against covered entities for drug diversion or multiple discounts. Authorization of Appropriations Funding (FY2011-FY2013) SSAN for FY2010 and each succeeding fiscal year. FY2011 funding = $4 million, FY2012 funding = $4 million, FY2013 request = $6 million (proposed new user fee program). Sources: Table 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). FY2011, FY2012 and requested FY2013 funding amounts are taken from HRSA’s FY2013 budget justification document for Congress, available at http://www.hrsa.gov/ about/budget/index.html. Table 13. ACA Discretionary Spending: Medical Malpractice Statutory Authority (Agent) ACA Section 10607 New PHSA Sec. 399V-4 (HRSA) Summary of Provision Liability reform demonstration program. Authorizes five-year demonstration grants to states for the implementation and evaluation of alternatives to current tort litigation for resolving disputes over injuries allegedly caused by health care providers or organizations. Planning grants of up to $500,000 may be awarded to states for the development of demonstration project applications. To receive a grant, a state must develop an alternative system that allows for the resolution of disputes caused by health care providers or organizations, and reduces medical errors by encouraging the collection and analysis of patient safety data related to the resolved disputes. Authorization of Appropriations Funding (FY2011-FY2013) $50 million for the period FY2011 through FY2015. Source: Table 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). CRS-35 Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) Table 14. ACA Discretionary Spending: Pain Care Management Statutory Authority (Agency) ACA Section 4305(a) New authority Authorization of Appropriations Funding (FY2011-FY2013) Summary of Provision Conference on pain. Requires the Secretary, within one year of appropriating funds, to contract with the IOM to convene a Conference on Pain for the purpose of assessing the public health impact of pain, reviewing pain research, care, and education, and identifying barriers to improved pain care. A report summarizing the Conference’s findings must be submitted to Congress by June 30, 2011. [Note: IOM released its report on June 29, 2011. See http://painconsortium.nih.gov/.] SSAN for each of FY2010 and FY2011. Source: Table 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). Table 15. ACA Discretionary Spending: Medicaid Statutory Authority (Agency) ACA Section Summary of Provision Authorization of Appropriations Funding (FY2011-FY2013) 2705 New authority (CMS) Global payment system demonstration program. Requires the Secretary, in coordination with the Center for Medicare and Medicaid Innovation, to fund up to five Medicaid demonstrations during the period FY2010 through FY2012 under which a participating state will adjust payments made to a large safety net hospital system or network from a fee-for-service model to a global capitated payment model. SSAN (no years specified). 2706 New authority (CMS) Pediatric accountable care organization demonstration program. Requires the Secretary to conduct a five-year Medicaid demonstration (Jan. 1, 2012 through Dec. 31, 2016) under which a participating state is allowed to recognize pediatric providers as an accountable care organization (ACO) for the purpose of receiving incentive payments. Eligible pediatric providers must meet certain performance guidelines established by the Secretary to be recognized as an ACO, and must achieve a specified minimum level of Medicaid savings to receive an incentive payment. SSAN (no years specified). Source: Table 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). CRS-36 Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) Table 16. ACA Discretionary Spending: Medicare Statutory Authority (Agency) ACA Section 3129 Amends and reauthorizes SSA Sec. 1820 (HRSA) Summary of Provision Rural hospital flexibility grant program. Extends authorization of appropriations for the rural hospital flexibility (Flex) grants that support a range of performance and quality improvement activities at small rural hospitals. Permits the funding to be used to help rural hospitals participate in delivery system reform programs authorized under ACA. Authorization of Appropriations Funding (FY2011-FY2013) SSAN for each of FY2011 and FY2012, to remain available until expended. FY2011 funding = $41 million, FY2012 funding = $41 million, FY2013 request = $26 million. [CFDA 93.241] Sources: Table 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). FY2011, FY2012 and requested FY2013 funding amounts are taken from HRSA’s FY2013 budget justification document for Congress, available at http://www.hrsa.gov/ about/budget/index.html. Table 17. ACA Discretionary Spending: Private Health Insurance Statutory Authority (Agency) ACA Section 1334 New authority (OPM) Summary of Provision Multi-state health plans. Requires OPM to contract with health insurers to offer at least two multi-state health plans (at least one nonprofit) through exchanges in each state. Authorizes OPM to prohibit multi-state plans that do not meet standards for medical loss ratios, profit margins, and premiums. Requires multi-state plans to cover essential health benefits and meet all the requirements of a qualified health plan. Authorization of Appropriations Funding (FY2011-FY2013) SSAN (no years specified). Source: Table 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). CRS-37 Discretionary Spending in the Patient Protection and Affordable Care Act (ACA) Author Contact Information C. Stephen Redhead, Coordinator Specialist in Health Policy credhead@crs.loc.gov, 7-2261 Sarah A. Lister Specialist in Public Health and Epidemiology slister@crs.loc.gov, 7-7320 Kirsten J. Colello Specialist in Health and Aging Policy kcolello@crs.loc.gov, 7-7839 Amanda K. Sarata Specialist in Health Policy asarata@crs.loc.gov, 7-7641 Elayne J. Heisler Analyst in Health Services eheisler@crs.loc.gov, 7-4453 Acknowledgments Pamela W. Smith provided extensive editorial comments during the development of the initial version of this report. Key Policy Staff Area of Expertise Health Centers and Clinics Health Care Workforce Long-Term Care Prevention and Wellness Maternal and Child Health Health Care Quality Nursing Homes Health Disparities Emergency Care Elder Justice Biomedical Research Biologics 340B Drug Pricing Medical Malpractice Pain Care Management Medicaid Medicare Private Health Insurance Congressional Research Service Name Elayne J. Heisler C. Stephen Redhead Elayne J. Heisler Bernice Reyes-Akinbileje Kirsten J. Colello Sarah A. Lister Emilie Stoltzfus Amalia Corby-Edwards Amanda K. Sarata Cliff Binder Amalia Corby-Edwards Elayne J. Heisler Kirsten J. Colello Pamela W. Smith Judith A. Johnson Cliff Binder Vivian S. Chu Kirsten J. Colello Cliff Binder Sibyl Tilson Bernadette Fernandez Phone 7-4453 7-2261 7-4453 7-2260 7-7839 7-7320 7-2324 7-0423 7-7641 7-7965 7-0423 7-4453 7-7839 7-7048 7-7077 7-7965 7-4576 7-7839 7-7965 7-7368 7-0322 E-mail eheisler@crs.loc.gov credhead@crs.loc.gov eheisler@crs.loc.gov breyes@crs.loc.gov kcolello@crs.loc.gov slister@crs.loc.gov estoltzfus@crs.loc.gov acorbyedwards@crs.loc.gov asarata@crs.loc.gov cbinder@crs.loc.gov acorbyedwards@crs.loc.gov eheisler@crs.loc.gov kcolello@crs.loc.gov psmith@crs.loc.gov jajohnson@crs.loc.gov cbinder@crs.loc.gov vchu@crs.loc.gov kcolello@crs.loc.gov cbinder@crs.loc.gov stilson@crs.loc.gov bfernandez@crs.loc.gov 38